FORM - 4 (See rule - 14) The Licencing Authority, _______________________ I enclosed Learners Licence No.____________________Dt._________________Issued by L.A._________________. I hereby apply for a Licence authorising me to drive the following vehicles ( Tick at the appropriate box)
1. FULL NAME (Leave one Space between first and last name) 2. Son/Daughter/Wife of
Disclaimer : The applicant is solely responsible for any medical complications that may arise due to wrong declaration of the Blood group. 9. Particulars and date of every conviction which has been ordered to be endorsed on __________________ any Licence held by the applicant. 10. Particulars of disqualification of the applicant from obtaining a Licence to drive,and reasons for it. ________________________ 12. I enclose the Driving Certificate No. ______________________ Dated _____________________ Issued by____________________________________________.
Note:Strike out whichever is inapplicable. ______________________ Signature/Thumb Impression
of applicant
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