FORM 9 Appl No.

2106831519 Dt:16-07-2019
[See rule 18(1)]
FORM OF APPLICATION FOR THE RENEWAL OF DRIVING

I, Smt/Kum :: KAISAR MUKADAM

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Father's Name :: BILAL MUKADAM

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hereby apply for the renewal of my driving licence which is attached and particulars of which are as

a) Driving Licence Number :: MH02 20100030820

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b) Date of issue :: 17-07-1999

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c) Licensing Authority by which the licence :: DY.RTO,BORIVALI

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issued

d) Licensing Authority by which the licence :: RTO,MUMBAI (WEST

was last renewed, number and date of .................................................
renewal MH02 /AED/0007102/2013 Dt: 06-06-2013
.................................................

e) Class of vehicles authorised to be driven :: MCWG , LMV

f) Date of expiry of licence to drive ::

(i) transport vehicle :: ................................................

(ii) vehicles other than transport :: 16-07-2019

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My present address is :: R/24, HAJRA BAI CHL, MAKRANI PADA

MALAD (E),
GREATER MUMBAI,MUMBAI SUBURBAN
400097

If this address is not entered on the :: R/24, HAJRA BAI CHL, MAKRANI PADA, MALAD (E),,
licence I do/do not wish that it should be GREATER MUMBAI,MUMBAI SUBURBAN, 400097
so entered.

If the licence is not attached, reasons :: ................................................

why it is not available?
If the licence was not renewed within thirty :: ................................................
days of the days of the date of expiry,
reaons for delay

The renewal of licence has not been :: ................................................

refused by any Licensing Authority.

I have not been disqualified for holding or :: ................................................

obtaining a driving licence. My licence has
not been revoked.

I enclose three copies of my recent :: ................................................

passport size photographs.

I have paid the fee of Rs. :: 466.00

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Challan No. / Receipt No. :: MHS/2834917 Dt : 16-07-2019
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I hereby declare that to the best of my knowledge and belief the particulars given above are true.

Date: 16-07-2019 Signature or thumb impression of the

KAISAR MUKADAM
Name ………………………………….

Address
 CMV FORM 1 Appl No: 2106831519 Dt:16-07-2019
[See rule 5(2)]
Application –cum-declaration as to the physical fitness

1.Name of the applicant : KAISAR MUKADAM

2. Father's Name : BILAL MUKADAM

3.Permanent address : R/24, HAJRA BAI CHL, MAKRANI PADA

MALAD (E),
GREATER MUMBAI,MUMBAI SUBURBAN
400097

4.Temporary address : R/24, HAJRA BAI CHL, MAKRANI PADA

Official address (if any) MALAD (E),
GREATER MUMBAI,MUMBAI SUBURBAN
400097

5. (a) Date of birth : 25-10-1979

(b) Age on date of application : 39 years
6. Identification marks :

Declaration :

(a) Do you suffer from epilepsy, 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 licence 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 Yes / No
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 Yes / No
from any defect in movement, control or muscular power of either
arm or leg ?

(d) Can you readily distinguish the pigmentary colours, red Yes / No
and green ?

(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 or without Yes / No
hearing aid) the ordinary sound signal ?
(g) Do you suffer from any other disease or disability likely to
cause your driving of a motor vehicle to be a source of danger
Yes / No
to the public, if so, give details?

I hereby declare that, to the best of my knowledge and belief, the particulars given above and the declaration
made therein are true.

Signature or thumb impression of the applicant

( KAISAR MUKADAM )

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 thereto.
(2) This declaration is to be submitted invariably with Medical Certificate in Form 1-A.