NEW

Application Number Form of Application for New Licence to Drive a Motor Vehicle (Read the instructions on page-5 carefully before filling the form) To, The Licensing Authority State * Name of the RTO/DTO UID

584045 *
LL DL

GJ-Gujarat

GJ05 -RTO,SURAT

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Part A
First Name 1. Name of the applicant Gender

Middle Name

Last Name

MAYUR
Male
18-09-1996

DIPAK
Female Others or 1.2 Age(In Years) 16

KADAM

1.1 Date of birth * (dd-mm-yyyy) 2. Place of Birth

SURAT

2(a) If place of birth is out side India, Month & Year when migrated to India: Month 3 .Country by Birth 3(a) Email Address 4. Name of Year

IND-INDIA
MAYURKADAM189@GMAIL.COM
Father First Name* Mother Husband Guardian Middle Name Last Name

DIPAK
5. Permanent address :(Proof to be enclosed)

KADAM
6. Present Address Present Address is same as Permanent Address

a) Flat Number b) Flat / House Name c) House Number/Plot No d) Street e) Locality f) Village / Town / City g) Taluka / Mandal h) District i) State j) PIN code * k) Phone l) Mobile

1002 AMARKIRTI APPARTMENT

1002 AMARKIRTI APPARTMENT

JAMNANAGAR BUSSTOP GHODDHOD ROAD

SURAT

JAMNANAGAR BUSSTOP GHODDHOD ROAD

SURAT

SURAT SURAT
GJ-Gujarat
395001

SURAT SURAT
GJ-Gujarat
395001

7405255843
16

7405255843
Months Registration Descent Naturalization
16

m) Duration of Stay at this address 7. Citizenship Status By

Years Birth

Years Non Indian

Months

* *

8. Education Qualification 9. Identification marks 10.Blood Group *

10-+2/Intermediate/ICSE (12th )/CBSE(12th)

A+

Part B
11*Requested Transaction Service (with class of vehicle) S.No. DESCRIPTION OF VEHICLE TYPE

Application Number

584045
New DL

New LL

1
2

MOTOR CYCLE WITHOUT GEAR(NON TRANSPORT)-(MCWOG )

MOTOR CYCLE WITH GEAR (NON TRANSPORT)-(MCWG )

3
4 5
6 7

LMV -3 WHEELER NT-(3W-NT )

LMV-NT-CAR-(LMV ) LMV-TRACTOR-NT-(TRCTOR)
MOTOR CYCLE WITH GEAR (TRANSPORT)-(MCWGT ) MOTOR CYCLE WITH GEAR(TRANSPORT)PSV-(MCWGP )

LMV -3 WHEELER CAB-(3W-CAB)

9
10 11

LMV -3 WHEELER TRANSPORT GOODS NON PSV-(3W-GV )

LMV-TRANSPORT-PSV-CAB-(LMVCAB) LMV (TRANSPORT)-(LMV-GV)

12 13
14 15

LMV-TRACTOR TRAILER(TRANSPORT)-(LMV-TT) TRANSPORT VECHICLE - M/HMV(RIGID CHASSIS) - GOODS-(TRANS )

TRANSPORT VEHICLE-M/HMV(RIGID CHASSIS) PSV-BUS-(PSVBUS) TRANSPORT VEHICLE-M/HMV-ARTICULATED-(MVHART)

16 17 18
19

TRANSPORT VEHICLE-M/HMV - TRACTOR TRAILER-(TRCTRL) INVALID CARRIAGE VEHICLE-(INVCRG) ROAD ROLLER-(RDRLR )

OTHERS - CONSTRUCTION EQUIPMENTS-(CNEQP )

Registration Certificate(RC) Number

Part C
12) List of Enclosures (for Age Proof, Address Proof etc.,) Document Type
-None-

Licence Number/Certificate No./Badge No., etc

Issuing Authority/Institute

Date of Issue (DD-MM-YYYY)

-None-

Part - D
13) I have submitted along with my application for Learners Licence the written consent of my parent/guardian: - (For Candidates having age below 18 years) 14) I have submitted along with my application for Learners Licence , I enclosed all the Necessary Enclosures / Certificates: 15) I am exempted from the Medical test under rule 6 of the Central Motor Vehicles Rules, 1989 :16) I am exempted from preliminary test under rule 11(2) of the Central Motor Vehicles Rules, 1989 :17) I have been convicted / disqualified / my Licence was cancelled /suspended / my Licence was revoked Yes No

Yes Yes Yes Yes

No No No No

Application Number (If Yes, attach Documents): If Yes, DL Number Reason

584045

Date of Conviction (dd-mm-yyyy)

I hereby declare that to the best of my knowledge and belief the particulars given above are true and I have enclosed all the necessary documents required as per the rules.

Date

Signature or Thumb impression of the Applicant MAYUR DIPAK KADAM

Part - E
UNDER SECTION 7(2) OF THE MOTOR VEHICLES ACT, 1988 Shri / Kumari son/daughter of

...................................................................... ......................................................................
who is a minor is under my care and I accept forhis/her driving .

If at a later date I decide not to accept responsibility for his/her driving I shall intimate the licensing authority in writing for the cancellation of the licence. I give my consent for his/her obtaining learners licence.

Name and full address of the parent/guardian Name of the Guardian Address City District Pincode Relationship : : : : : :

Signature of Parent/Guardian

...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ......................................................................

(To be signed in the presence of the licensing authority or person authorized in this behalf by the licensing authority)

Part - F
FOR OFFICE USE 1) The applicant is exempted from the medical test under r. 6 and the preliminary test under r. 11(2) of the Central Motor Vehicles Rules, 1989. Learners licence may be issued 2) The applicant was tested with reference to r. 11(1) of the Central Motor Vehicles Rules, 1989. He has passed the test. Learners licence may be issued 3) He / She has failed in

............. .............

............. LL ............. DL ......................................................................

(Reasons should be specified)

4) Registration Mark(s) of the vehicle(s) on which Driving Skill test was conducted S.No. Class of Vehicle Registration Mark of the vehicle Details of Skill Test

Result

Application Number

584045 .............

5) Learners licence may be refused. 6) Signature of licensing authority or other person authorized in this behalf. *Strike out whichever is inapplicable.

Signature of the Issuing Authority

Print

Submit

Instructions for filling up theUnified Application Form for New Learner Licence / Driving Licence
1. 2. 3. 4. 5. 6. This form can be used for applying for New Learners Licence (LL) or Driving Licence (DL). Please fill up the data in Boxes with CAPITAL letters only. Columns marked as ( *) are mandatory. Enclosures: The Applicant should produce the proof for claims made in the Application where ever necessary. A set of codes defined for each of such type of enclosures is shown in HELP section ( See Code List -A,B,C). The Licensing Authority Code or RTO Code: The RTO/DTO office under whose jurisdiction the applicant resides or his/her place of business. Name of the Applicant : Fill the Applicant's name in the order of first name, middle name and surname/family name. However ensure that the name is entered as per the relevant records being produced as proof. Eg. JANGA REDDY CHEBANDI, DEVSINGH NAIK, SULTAN ISMAIL MOHAMMED Class or type of Vehicle(COV): Different class of vehicles are given in column 1 1. at least one class / type of vehicle should be selected to fill the unified application form. Part -A: If you are not holding an LL/DL please fill in all relevant columns i.e. 1 -9 of Part-A Part-B: It is mandatory to specify the class of v ehicles for which the LL/DL is to be issued from column 1 1 (Required Transaction Services) by putting tick ( ) mark. reference Part-C: It is mandatory to fill column 1 2 to provide details on the required documents like age proof, qualification proof etc. The number of the document enclosed also should be written as proof. If you are holding a DL or LL , please mention those details also in these columns. Part-D: The applicant shall fill this part wherever applicable. Part-E: If the Applicant is minor, this form can be filled by her/his parents and the licensing authority shall mention in the endorsement. Part-F: For Office Use only.

7. 8. 9. 10.

11. 12. 13.

Glossary
RTO - Regional Transport Office DL - Driving Licence PSV - Public Service Vehicle DTO - District Transport Office COV - Class/Type of Vehicle LL - Learners Licence

HELP for Unified Application Form for Licence to Drive Motor Vehicle
CODE LIST A (TYPE OF ENCLOSURES SUPPORTING THE CLAIM MADE IN THE APPLICATION) TYPE DESCRIPTION TYPE DESCRIPTION
A B C D E F H I Age Proof Psv Badge First Aid Certificate Driving Licence (DL) Educational Certificate FIR(First Information Report) Hill Driving Training Certificate International Driving Permit (IDP) L M N P T V X Z Learners Licence (LL) Medical Fitness Ration Card Passport Driving Training Certificate Visa Military Licence Hazardous Training Certificate

CODE LIST B ( EDUCATIONAL QUALIFICATIONS) S.No DESCRIPTION

00 01 02 03 04 06 07 10 11 12 13 14 30 31 32 33 34 35
Illiterate Not specified th Below 8 8th PASSED th 10 Class /SSC / SSLC / CBSE ( X ) / ICSE ( X ) ITI Certificate course th th +2 / Intermediate / ICSE (12 ) / CBSE (12 ) Diploma in Engineering (non Mechanical) Diploma in Mechanical Engineering Diploma in Other faculties DHMS B A / BBA / B. Com / B Sc Bachelor of Agriculture / Vet. Sciences B E ( other than Mechanical) B E (Mechanical) MBBS / BHMS / BAMS Bachelor of Education / Law

S.No
39 50 51 52 53 54 55 56 57 58 59 70 80 81 82 90 91

DESCRIPTION
Any Other Graduation Not specified above MA / MBA / M.Com / M.SC Post Graduate Diploma In Science / Arts / Commerce / Management Post Graduate Diploma In Engineering / Medicine M Sc (Agriculture / Vet. Sciences) M E ( other than Mechanical ) M E (Mechanical) MS / MD / MHMS / MAMS / MDS Master of Education / Law CA / ICWA / ICS or equivalent Any Other Post Graduation / PG Diploma Not specified above M Phil. ( Sciences / Arts / Commerce/ Education / Law / Management / other faculties) Ph.D. ( Sciences / Arts / Commerce/ Education / Law / Management / other faculties) Ph.D in Engineering Ph. D. in Medicine M. Ch. ( Surgery )/ D.M. ( Medicine ) D. SC. ( Sciences / Arts / Commerce / Education / Law / Management / other faculties)

CODE LIST

C (STA TE AND UNION TERRITORY CODE LIST)

CODE
AP AR AS BR CG DL GA GJ HR HP JK JH

STATE NAME
Andhra Pradesh Arunachal Pradesh Assam Bihar Chattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand

CODE
KA KL MP MH MN ML MZ NL OR PY PB RJ
Kerala

STATE NAME
Karnataka

CODE
SK TN TR UP UA WB CH AN DN DD LD
Sikkim Tamil Nadu Tripura Uttar Pradesh Uttarakhand West Bengal

STATE/ UT NAME

Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Pondicherry Punjab Rajasthan

Union Territories
Chandigarh Andaman & Nicobar Islands Dadra & Nagar Haveli Daman and Diu Lakshadweep

Note: Follow Instructions. See Help for Codes in the Annexure given along with this Unified Form for New LL/DL