NEW 586594
Application Number Form of Application for New Licence to Drive a Motor Vehicle
*
LL
DL
(Read the instructions on page-5 carefully before filling the form) To, The Licensing Authority
UID
State *
GJ-Gujarat
Name of the RTO/DTO
*
Save for Offline
GJ05 -RTO,SURAT
Part – A First Name 1. Name of the applicant
ROHIDAS
*
Male
Gender
1.1 Date of birth * (dd-mm-yyyy) 2. Place of Birth
*
Female
13-12-1990
Middle Name
Last Name
S
LONARI
Others or 1.2 Age(In Years) 22
VARNGAV
2(a) If place of birth is out side India, Month & Year when migrated to India: Month 3 .Country by Birth
IND-INDIA
*
[email protected]
3(a) Email Address 4. Name of
Year
*
Father
Mother
Husband
Guardian
First Name*
Middle Name
Last Name
SAMPAT
Y
LONARI 6. Present Address
5. Permanent address :(Proof to be enclosed)
Present Address is same as Permanent Address a) Flat Number b) Flat / House Name c) House Number/Plot No 22 d) Street
SANJAYNAGAR
e) Locality
LIMBAYAT
f) Village / Town / City
UDHNA YARD
g) Taluka / Mandal
CHOURYASI
h) District
SURAT GJ-Gujarat
i) State j) PIN code *
394210
k) Phone l) Mobile
*
8140318831
m) Duration of Stay at this address 7. Citizenship Status By
Years
*
8. Education Qualification
Birth
*
2-Below 8th
9. Identification marks 10.Blood Group *
A+
Months Registration
Descent
Years Naturalization
Non Indian
Months
Application Number
Part – B
586594
11*Requested Transaction Service (with class of vehicle) DESCRIPTION OF VEHICLE TYPE
S.No.
New LL
1
MOTOR CYCLE WITHOUT GEAR(NON TRANSPORT)-(MCWOG )
✔
2
MOTOR CYCLE WITH GEAR (NON TRANSPORT)-(MCWG )
✔
3
LMV -3 WHEELER NT-(3W-NT )
4
LMV-NT-CAR-(LMV )
5
LMV-TRACTOR-NT-(TRCTOR)
6
MOTOR CYCLE WITH GEAR (TRANSPORT)-(MCWGT )
7
MOTOR CYCLE WITH GEAR(TRANSPORT)PSV-(MCWGP )
8
LMV -3 WHEELER CAB-(3W-CAB)
9
LMV -3 WHEELER TRANSPORT GOODS NON PSV-(3W-GV )
10
LMV-TRANSPORT-PSV-CAB-(LMVCAB)
11
LMV (TRANSPORT)-(LMV-GV)
12
LMV-TRACTOR TRAILER(TRANSPORT)-(LMV-TT)
13
TRANSPORT VECHICLE - M/HMV(RIGID CHASSIS) - GOODS-(TRANS )
14
TRANSPORT VEHICLE-M/HMV(RIGID CHASSIS) PSV-BUS-(PSVBUS)
15
TRANSPORT VEHICLE-M/HMV-ARTICULATED-(MVHART)
16
TRANSPORT VEHICLE-M/HMV - TRACTOR TRAILER-(TRCTRL)
17
INVALID CARRIAGE VEHICLE-(INVCRG)
18
ROAD ROLLER-(RDRLR )
19
OTHERS - CONSTRUCTION EQUIPMENTS-(CNEQP )
New DL
Registration Certificate(RC) Number
Part – C 12) List of Enclosures (for Age Proof, Address Proof etc.,) Document Type A-Age Proof
E-Educational Certificate
Licence Number/Certificate No./Badge No., etc
Issuing Authority/Institute
Date of Issue (DD-MM-YYYY)
TFL3009628
GOVERMENT
06-01-2011
1229
NAGAR PRATHMIK
27-02-2005
Part - D 13) I have submitted along with my application for Learner’s Licence the written consent of my parent/guardian: - (For Candidates having age below 18 years)
Yes
No
14) I have submitted along with my application for Learner’s Licence , I enclosed all the Necessary Enclosures / Certificates: -
Yes
No
15) I am exempted from the Medical test under rule 6 of the Central Motor Vehicles Rules, 1989 :-
Yes
No
16) I am exempted from preliminary test under rule 11(2) of the Central Motor Vehicles Rules, 1989 :-
Yes
No
17) I have been convicted / disqualified / my Licence was cancelled /suspended / my Licence was revoked
Yes
No
Application Number
586594
(If Yes, attach Documents): Date of Conviction (dd-mm-yyyy)
If Yes, DL Number Reason
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 8-4-2013
Signature or Thumb impression of the Applicant ROHIDAS S LONARI
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 learner’s licence.
Name and full address of the parent/guardian
Signature of Parent/Guardian
Name of the Guardian
:
......................................................................
Address
:
......................................................................
City
:
......................................................................
District
:
......................................................................
Pincode
:
......................................................................
Relationship
:
......................................................................
(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. Learner’s 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. Learner’s 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
586594 .............
5) Learner’s 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
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Instructions for filling up theUnified Application Form for New Learner Licence / Driving Licence 1. 2. 3. 4. 5. 6.
7. 8. 9. 10.
11. 12. 13.
This form can be used for applying for New Learner’s 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.
Glossary RTO - Regional Transport Office DL - Driving Licence PSV - Public Service Vehicle
DTO - District Transport Office COV - Class/Type of Vehicle
LL - Learner’s 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
Age Proof
L
Learners Licence (LL)
B
Psv Badge
M
Medical Fitness
C
First Aid Certificate
N
Ration Card
D
Driving Licence (DL)
P
Passport
E
Educational Certificate
T
Driving Training Certificate
F
FIR(First Information Report)
V
Visa
H
Hill Driving Training Certificate
X
Military Licence
I
International Driving Permit (IDP)
Z
Hazardous Training Certificate
CODE LIST –B ( EDUCATIONAL QUALIFICATIONS) S.No DESCRIPTION
S.No
DESCRIPTION
39 50 51 52
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
53
M Sc (Agriculture / Vet. Sciences)
06 07 10 11 12 13
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
54 55 56 57 58 59
14
DHMS
70
30
B A / BBA / B. Com / B Sc
80
31 32 33
Bachelor of Agriculture / Vet. Sciences B E ( other than Mechanical) B E (Mechanical)
81 82 90
34
MBBS / BHMS / BAMS
91
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)
35
Bachelor of Education / Law
00 01 02 03 04
CODE LIST
–C (STA TE AND UNION TERRITORY CODE LIST)
CODE
STATE NAME
CODE
AP
Andhra Pradesh
AR
Arunachal Pradesh
AS
Assam
MP
BR
Bihar
CG
STATE NAME
CODE
STATE/ UT NAME
KA
Karnataka
SK
Sikkim
KL
Kerala
TN
Tamil Nadu
Madhya Pradesh
TR
Tripura
MH
Maharashtra
UP
Uttar Pradesh
Chattisgarh
MN
Manipur
UA
Uttarakhand
DL
Delhi
ML
Meghalaya
WB
West Bengal
GA
Goa
MZ
Mizoram
GJ
Gujarat
NL
Nagaland
CH
Chandigarh
HR
Haryana
OR
Orissa
AN
Andaman & Nicobar Islands
HP
Himachal Pradesh
PY
Pondicherry
DN
Dadra & Nagar Haveli
JK
Jammu and Kashmir
PB
Punjab
DD
Daman and Diu
JH
Jharkhand
RJ
Rajasthan
LD
Lakshadweep
Union Territories
Note: Follow Instructions. See Help for Codes in the Annexure given along with this Unified Form for New LL/DL
