Annex A

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF TRANSPORTATION LTO FORM NO.
21
LAND TRANSPORTATION OFFICE
East Avenue, Quezon City No.
DISTRICT OFFICE

APPLICATION FOR
STUDENT DRIVER'S PERMIT / DRIVER'S LICENSE / CONDUCTOR'S LICENSE (APL)
1. ACCOMPLISH THE FORM COMPLETELY 3. SUBMIT THIS FORM TO THE CSR/EVALUATOR TOGETHER WITH
INSTRUCTION
S 2. PRINT DATA LEGIBLY IN CAPITAL THE REQUIRED SUPPORTING DOCUMENTS
LETTERS
NAME(Family Name, First Name, Middle Name)

PRESENT ADDRESS (No., Street, City/Municipality,Province) TEL.NO. / CP NO. TIN

NATIONALITY SEX (M/F) BIRTH DATE(YYYY/MM/DD) HEIGHT(cm) WEIGHT(kg)

LICENSE
NUMBER
CIVIL STATUS (CS) BIRTHPLACE (City, Municipality, Province)
1. SINGLE 2.
3. 4. SEPARATED
MARRIED
WIDOWED FATHER'S NAME(Family Name,First Name,Middle Name)(indicate even if deceased)
HIGHEST EDUCATIONAL
LICENSE CLASSIFICATION DRIVING SKILL ACQUIRED FROM (FOR DL APPLICANTS ONLY)
APPLIED FOR (LCA) ATTAINMENT (EA)

1 DRIVING SCHOOL MOTHER'S NAME(Family Name,First Name,Middle Name)(indicate even if deceased)

1 STUDENT-DRIVER'S POSTGRADUAT
E
PERMIT (SP) INSTRUCTOR
COLLEGE SPOUSE NAME(Family Name,First Name,Middle Name)(indicate even if deceased)
2 PRIVATE LICENSED PERSON with DL NO.
2 DRIVER'S LICENSE NAME
(DL) HIGH
3 TESDA SCHOOL EMPLOYER'S BUSINESS NAME TEL. NO
3
CONDUCTOR' INSTRUCTOR
S LICENSCE
ELEMENTARY
(CL)

BLOOD TYPE ORGAN ALL HEART EYES LIVER BONES EYES COLOR EMPLOYER'S BUSINESS ADDRESS
DONOR
YES NO KIDNEYS CORNEA PANCREAS LUNGS SKIN
EMERGENCY CONTACT PERSON
TYPE OF APPLICATION (TOA)
EMERGENCY CONTACT ADDRESS EMERGENCY CONTACT NO.
A. NEW G. DUPLICATE I4. CHANGE BIRTH DATE

H. DROPPING OF CATEGORY OR ADD'L OR I5. Others AGENCY CODE

B. RENEWAL REMOVAL OF DRIVING CONDITIONS
C. CONVERSION OF FOREIGN DL
I. REVISION OF RECORDS
D. ADDITIONAL CODE OR CATEGORY I1. CHANGE
J. ENHANCEMENT OF DL ISSUE DATE EXPIRY DATE
ADDRESS

E. CHANGE OF DL CLASSIFICATION I2. CHANGE CIVIL STATUS K. CHANGE OF CLUTCH TYPE

F. EXPIRED DL WITH VALID FDL I3. CHANGE NAME

DRIVER'S LICENSE VEHICLE CATEGORY

CLUTC
EXISTING
APPLIED NON H
VEHICLE CATEGORY sv PRO TYPE
FOR PRO
AT MT
LIGH
TA
MOTORCYCLE
L1 Two wheels with a maximum design speed not exceeding 50 kph
L2 Three wheels with a maximum design speed not exceeding 50 kph
L3 Two wheels with a maximum design speed exceeding 50 kph

A1 TRICYCLE
L4 Motorcycle with side cars with a maximum design speed exceeding 50 kph
L5 Three wheels symmetrically arranged with a maximum design speed exceeding 50 kph
L6 Four wheels whose unladen mass is not more than 350kg with maximum design speed not exceeding 45 kph
L7 Four wheels whose unladen mass is not more than 550kg with maximum design speed not exceeding 45 kph

B M1 Vehicles used for the carriage of passengers and comprising not more than 8 seats in
addition to the driver's seat with GVW up to 5000kgs.

B1 M2 Vehicles used for the carriage of passengers, comprising more than 8 seats in addition to the
driver's seat with GVW up to5000kgs.

B2 LIGHT COMMERCIAL
VEHICLES
N1 Vehicles used for the carriage of goods and having a GVW up to 3500kgs.

HEAVY
C HEAVY COMMERCIAL
VEHICLES
N2 Vehicles used for the carriage of goods and having a maximum GVW exceeding 3500kgs
but not exceeding 12000kgs
N3 Vehicles used for the carriage of goods and having a maximum GVW exceeding 12000kgs.

D BUSES, COACHES and OTHER PASSENGER VEHICLES

M3 Vehicles used for the carriage of passengers, comprising more than 8 seats in addition to the
driver's seat and having a maximum GVW exceeding 5000kgs.

BE ARTICULATED PASSENGER CARS - Vehicles with trailer GVW of no more than 3500kgs.
O1 Trailers with a maximum GVW not exceeding 750kgs.
O2 Trailers with a maximum GVW exceeding 750kgs, but not exceeding 3500kgs.

CE HEAVY ARTICULATED VEHICLES - Articulated Commercial Vehicles with trailer GVW of more than
3500kgs
O3 Trailers with a maximum GVW exceeding 3500kgs, but not exceeding
10000kgs. O4 Trailers with a maximum GVW exceeding 10000kgs.
CONDITIONS
1 WEAR CORRECTIVE LENSES 2 DRIVE ONLY W/ SPECIAL EQUIPMENT FOR UPPER LIMBS/LOWER LIMBS
3 DRIVE CUSTOMIZED MOTOR VEHICLE ONLY 4 DAYLIGHT DRIVING ONLY 5 HEARING AID IS REQUIRED
FILL THIS UP ONLY IF YOUR NAME ABOVE IS DIFFERENT FROM YOUR NAME IN PREVIOUS LICENSE
 THIS IS TO CERTIFY UNDER PREVIOUS NAME (Family Name, First Name, Middle Name) TO BE ACCOMPLISHED BY LTO PERSONNEL ONLY
PENALTY OF PERJURY THAT THE THIS IS TO CERTIFY THAT I HAVE CAREFULLY EVALUATED THIS
INFORMATION I HAVE GIVEN IS APPLICATION INCLUDING THE SUPPORTING DOCUMENTS
TRUE AND CORRECT
BY SIGNING THIS FORM, I VOLUTARILY AUTHORIZE LTO TO ALLOW DISCLOSURE OF THE
ABOVE PERSONAL INFORMATION TO ANY AUTHORIZED GOVERNMENT AGENCY

PRINT NAME AND SIGNATURE

PRINTED NAME AND SIGNATURE (EVALUATOR)
Annex A1 - Back portion of APL

ROAD TEST SCORE

SHEET

I HEREBY RELIEVE THE LTO AND ITS DULY AUTHORIZED NOTE: AN APPLICANT HAS 100 POINTS AT THE START OF THIS TEST.
REPRESENTATIVE OF RESPONSIBILITIES ARISING FROM ANY NUMBER OF POINTS IS DEDUCTED FOR ERRORS COMMITTED.
PASSING SCORE IS 80. THE TEST WILL IMMEDIATELY BE
DAMAGE OR ACCIDENTS DURING THE CONDUCT OF THIS
DISCONTINUED AND COUNTED AS FAILURE UPON
ACTUAL DRIVING TEST, SUCH AS, BUT NOT LIMITED TO THE ACCUMULATION OF MORE THAN 20 DEMERIT POINTS.
FOLLOWING:

1. STRIKING ANOTHER CAR 4. IMPROPER ACTION CAUSING VEHICLE CATEGORY

2. STRIKING A PEDESTRIAN COLLISION OR NEAR (REFER TO DRIVER'S LICENSE CLASSIFICATION)
3. STRIKING ANY FIXED OBJECT COLLISION OF OTHER
VEHICLE PLATE NO. PLATE NO. PLATE NO.
THE TEST WILL IMMEDIATELY BE DISCONTINUED AND COUNTED AS
FAILURE.

PRINT NAME AND SIGNATURE

APPLICANT
TOTAL DEMERIT
DEMERIT TOTAL DEMERIT TOTAL DEMERIT TOTAL
POINTS WEIGHT
1. PRE DRIVING CHECK UP 10
1.1 CHECK TIRES AND BATTERIES 2
1.2 CHECK/CLEAN/ADJUST MIRRORS, LIGHT AND WINDSHIELD 2
WIPER
1.3 USE SEATBELT/HELMET 2
1.4 CHECK HAND AND FOOT BRAKE 2
1.5 DISENGAGE CLUTCH WHEN STARTING ENGINE 2
2. DRIVING SKILLS 50
2.1 STEERING 2.1.1 POSITION OF HANDS 2
2.1.2 SMOOTHNESS 2
2.1.3 TWO HAND GRIP 2
2.1.4 OVER STEERING 2
2.2 ENGINE CONTROL 2.2.1 USE OF GEAR 2
2.2.2 CHOOSE OF GEARS 2
2.2.3 USE OF CLUTCH 2
2.2.4 USE OF ACCELERATOR 2
2.3 USE OF BRAKES 2.3.1 APPLY SMOOTH BRAKING 3
2.3.2 REACTIONS TO HAZARDS 3
2.3.3 VEHICLE TURNING 3
2.4 SPEED CONTROL 2.4.1 OBSERVANCE OF SPEED LIMIT 3
2.4.2 NEEDLESS STOPS 2
2.4.3 OBSERVANCE TO TRAFFIC 4
RULES
2.5 TURNING LEFT, 2.5.1 TAKES PROPER LANE 2
TURNING RIGHT
AND U-TURN
2.5.2 SIGNAL INTENTION 2
2.5.3 USE OF HAND AND LIGHT SIGNAL 2
2.5.4 SWINGS TOO WIDE AND CUTS 4
TOO SHORT
2.6 BACKING 2.6.1 NUMBER OF ATTEMPTS 2
2.6.2 CONTROL OF VEHICLE/ TRAILER 2
2.7 PARKING 2.7.1 NUMBER OF ATTEMPTS 2
3. OBSERVANCE TO TRAFFIC RULES 40
3.1 RIGHT OF WAY TO 3.1.1 WHILE APPROACHING 5
OTHER VEHICLES INTERSECTION
3.1.2 IN CHANGING LANES 3
3.1.3 IN PASSING/BEING PASSED 3
3.2 STOP 3.2.1 OBEY TRAFFIC SIGNS 4
LIGHTS/ SIGNALS
& OTHERS
3.2.2 POSITION AFTER STOPPING 4
3.2.3 MAKING FULL STOP WHEN 2
NECESSARY
3.2.4 ANTICIPATING BEFORE SIGNAL 3
CHANGES
3.2.5 EXERCISE DUE CARE FOR 3
PEDESTRIAN
3.3 RIGHT OF WAY 3.3.1 FOR OTHER VEHICLES 3
3.3.2 FOR PEDESTRIAN 3
3.3.3 FOR EMERGENCY 3
3.3.4 YIEDING OF RIGHT OF WAY 2
3.3.5 FOR BICYCLIST 2

TOTAL 100 100

DRIVING SKILLS RATER DATE CHIEF PRACTICAL EXAMINER APPROVED APPROVED APPROVED
CATEGORY CATEGORY CATEGORY
VEHICLE VEHICLE VEHICLE
CATEGORY CATEGORY CATEGORY
AT AT AT

MT MT MT
PRINT NAME/SIGNATURE PRINT NAME/SIGNATURE

APPROVED /
COMMENTS / RECOMMENDATION RECOMMENDED VEHICLE
CATEGORY/IES
DISAPPROVED
HEAD OF LICENSING CENTER

note : Provide another form if needed.