Beruflich Dokumente
Kultur Dokumente
"FORM 2"
[See rule 10]
4839507
I here by apply for a licence authorising me to drive as a learner, the following motor vechicle(s):1)
2)
MCWOG
MCWG
RAJENDRA E
2. Son of
ERAPPA
3. Permanent address
(Electoral Roll / Life Insurance Policy / Passport / Pay Slip issued by any
office of the Central Government / State Government or a local body /
Any other documents as may be prescribed by the State Government /
Affidavit sworn before an executive magistrate or a First Class Judicial
Magistrate or a Notary Public to
10TH
CROSS
BILEKAHALLI
BANGALORE
BANGALORE
KA
PIN : 560076
: 62/1
: 62/1
10TH
CROSS
BILEKAHALLI
BANGALORE
BANGALORE
KA
PIN : 560076
....................................................
: 12-Apr-1979
6. Date of birth
(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
.......................................................
....................................................
: 10th Class /SSC/ SSLC/CBSE (X)
9. Education Qualification
10 Identification Mark(s)
Blood Group
12 RH(Rhesus) factor
O+
IND
....................................................
....................................................
....................................................
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 Rs
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.
RAJENDRA E
1.
2.
CMV FORM 1
Web Appl No
4839507
RAJENDRA E
ERAPPA
3.Permanent address
62/1
10TH
CROSS
BILEKAHALLI
BANGALORE
BANGALORE
KA
PIN : 560076
62/1
10TH
CROSS
BILEKAHALLI
BANGALORE
BANGALORE
KA
PIN : 560076
4.Temporary address
Official address (if any)
12-Apr-1979
35 Years
Declaration :
(a) Do you suffer from eplipsy or from sudden attacks of
loss of consciousness or giddiness from any cause ?
(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
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
any defect in movement, control or muscular power of
either arm or leg ?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
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
RAJENDRA E
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.