"FORM 2/4" WebAppl 29440965
[See rule 10/14(1)]
FORM FOR THE GRANT OF LEARNER'S / DRIVING LICENCE
To
The Licensing Authority, Space for Passport
size Photograph
RTO,AHMEDABAD
I here by apply for a licence authorising me to drive as a learner/driver, the following motor
1) MCWG
PARTICULARS TO BE FURNISHED BY APPLICANT
1. Full Name : SACHIN KUMAR GUPTA
2. Son of : NARMADA PRASAD GUPTA
3. Permanent address : 4/2 B WINGCASELA TOWER
(Electoral Roll / Life Insurance Policy / Passport / Pay Slip issued by any B WING
office of the Central Government / State Government or a local body / SATELLITE CROSS ROAD
Any other documents as may be prescribed by the State Government / SATELLITE
Affidavit sworn before an executive magistrate or a First Class Judicial AHMEDABAD
Magistrate or a Notary Public SATELLITE
AHMEDABAD
GJ
: 4/2 B WINGCASELA TOWER
4. Temporary address / Official address, if any
B WING
SATELLITE CROSS ROAD
SATELLITE
AHMEDABAD
SATELLITE
AHMEDABAD
GJ
5. Duration of stay at the present address
....................................................
6. Date of birth : 10-Feb-1982
(Birth certificate / school certificate / affidavit sworn before an
Executive Magistrate or a First Class Judicial Magistrate or a
Notary public to be enclosed).
7. Place of birth .......................................................
8. If place of birth out side India when migrated to India ....................................................
9. Education Qualification : MA / MBA / M.Com / M.SC
10 Identification Mark(s)
:
11 Declaration of citizenship status : IND
(i) If deemed Citizen or Citizen by Birth
(Birth certificate and school certificate)
(In Support of Citizen ship as Indian to be enclosed)
(ii) If Citizenship is acquired by Descent / Registration
(In case Citizenship acquied by Descent, Birth Certificate,
land / property document of parent / in case of Citizenship acquired
by registration certificate to be enclosed)
(iii) If Citizenship by Naturalization
(Certificate of Naturalization and Certificate
of Registration to be enclosed)
(iv) If non-Indian Citizen
12 Blood Group : B+
RH(Rhesus) factor
13 I hold an effective driving licence to Drive: Motor Cycle /Light
Motor Vehicle / Transport Vehicle with effect from. ....................................................
14 Particulars of any driving licence previously held by applicant. Whether it was
cancelled and if so, for what reason ....................................................
15 Particulars of any learners licence previously held by applicant in respect of the
description of vehicle to which the applicant has applied. ....................................................
16 Have you been disqualified for holding or obtaining driving licence or learner's licence.
If so, for what reason. ....................................................
17 I enclose three copies of my recent photograph
(Passport size photograph)
18 I enclose medical fitness certificate dated .................................... issued by ................................... doctor
19 I have submitted along with my earlier application for Learner's licence / I enclose the written consent of parent / guardian ( In
the case of applicant being a minor)
20 I enclose driving certificate dated ..................... issued by ............................................... (Name and address of the driving
school)
21 Have paid the fee of
22 I am exempted from the medical test under rule 6 of the Central Motor Vehicles Rules, 1989.
23 I am exempted from the preliminary test under rule 11(2) of the Central Motor Vehicles Rules 1989.
* Strike out whichever is inapplicable
Date............................
Signature or Thumb impression of
Specimen Signature or Thumb impression of Applicant.
SACHIN KUMAR GUPTA
1. ------------------------------------
2.--------------------------------------
Declaration under sub-section(2) of section 7 of the Motor Vehicle Act 1988
Shri / Smt / Kumari ................................. Son / daughter of ........................................... who is a minor is under my care and I
accept responsibility / for his / her driving. If at a later date I decide not to accept responsibility of his/her driving, I shall
intimate the licence authority in writing for the cancellation of the licence. I give my consent for his/her obtaining learner's
License/Driving License.
Signature......................................................
Name and full address of the parent / guardian
............................................................................
............................................................................
Relationship....................................................
(To be signed in the presence of the licensing authority or person authorised in the behalf by the Licensing
For official use
The applicant is exempted from the medical test under rule 6 and the preliminary test under rule 11(2) of the Central Motor
Vehicles Rule, 1989.
Learner's licence may be issued.
The applicant was tested with reference of rule 11(1) of the Central Motor Vehicle Rules, 1989.
He has passed / failed in the priliminary test. Learner's Licence may be issued / rejected.
The applicant was tested with reference of rule 15 of the Central Motor Vehicle Rules, 1989.
He has passed / failed with Driving test. Driving Licence may be issued / rejected.
Signature of licensing authority or other
Person authorized in the behalf.
* Strike out whichever is inapplicable.
Note: The application along with the scanned copies of the required documents may also be sent to the concerned Licensing
Authority through Electronic Mail, if allowed by the concerned State Government / Union Territory
In such cases, the Licensing Authority shall scrutinse the application and intimate the applicant about the acceptance / any /
discrepancy.
In case the application is accepted, the applicant shall be intimated through Electornic mail to report to the Authority concerned on
a appointed date along with the documents for further verification, submission of application fee and examination of the applicant.
CMV FORM 1 Web Appl No 29440965
Application cum declaration as to the physical fitness
1.Name of the : SACHIN KUMAR GUPTA
: NARMADA PRASAD GUPTA
2.Son/ wife/ daughter
4/2 B WINGCASELA TOWER
3.Permanent address : B WING
SATELLITE CROSS ROAD
SATELLITE
AHMEDABAD
SATELLITE
AHMEDABAD
GJ
PIN : 380015
4/2 B WINGCASELA TOWER
4.Temporary address B WING
: SATELLITE CROSS ROAD
Official address (if any)
SATELLITE
AHMEDABAD
SATELLITE
AHMEDABAD
GJ
PIN : 380015
5. (a) Date of birth : 10-Feb-1982
(b) Age on date of : 35 Years
6. Identification Marks :
Declaration :
(a) Do you suffer from eplipsy or from sudden attacks of
loss of consciousness or giddiness from any cause ? Yes / No
(b) Are you able to distinguish with each eye ( or if you
have held a driving license to drive a motor vehicle for
a period of not less than five years and if you have lost,
the sight of one eye after the said period of five years and
if the application is for driving a light motor vehicle other
than a transport vehicle fitted with an outside mirror on
the steering wheel side) or with one eye, at a distance of Yes / No
25 metres in good day light (with glasses , if worn) a
motor car number plate?
(c) Have you lost either hand or foot or are you suffering from Yes / No
any defect in movement, control or muscular power of
either arm or leg ?
Yes / No
(e) Do you suffer from night blindness ? Yes / No
(f) Are you so deaf as to be unable to hear ( and if the
application is for driving a light motor vehicle, with Yes / No
or without hearing aid) the ordinary sound signal ?
(g) Do you suffer from any other disease or disability Yes / No
likely to cause your driving of a motor vehicle to be
a source of danger to the public, if so, give details?
I hereby declare that to the best of my knowledge and belief, the particulars
give above and the declaration made therein are true.
Signature or thumb impression of the applicant
SACHIN KUMAR GUPTA
Note : -
(1) An applicant who answers 'Yes' to any of the questions (a), (c),(e),
(f) and (g) or 'No' to either of the questions (b) and (d) should
amplify his answers with full particulars, and may be required to
give further information relating there to.
(2) This declaration is to be submitted invariably with Medical Certificate
in Form 1-A.
