Poppy Seeds

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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

263048 *
LL DL

KA-Karnataka

*

KA01 -RTO,KORAMANGALA

Part – A
First Name 1. Name of the applicant Gender

*

Middle Name

Last Name

Male

Female Others or 1.2 Age(In Years) 29

*

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

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
bhatmamta@gmail.com
Father First Name* Mother Husband Guardian Middle Name Last Name

*

5. Permanent address :(Proof to be enclosed)

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

A-207 ISHA LAKE FRONT

A-207 ISHA LAKE FRONT

SOMASUNDARA PALYA HARLKUNTE VILLAGE
HSR LAYOUT SECTOR 2

SOMASUNDARA PALYA HARLKUNTE VILLAGE
HSR LAYOUT SECTOR 2

BANGALORE
KA-Karnataka
560102

BANGALORE
KA-KARNATAKA
560102

9901199226

9901199226 9901199226
Months Descent Naturalization Years 9 Non Indian Months

*

9901199226
Years 9

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

* *

Birth

Registration

8. Education Qualification 9. Identification marks

32-B E ( other than Mechanical)

10.Blood Group *

O+

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

Application Number

263048
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 )

8

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 E-Educational Certificate

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

Issuing Authority/Institute

Date of Issue (DD-MM-YYYY)

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) 14) I have submitted along with my application for Learner’s 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

263048

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 MAMATA BHAT

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