FORM 2 1672931219 Dt:12-06-2019

[See rules 10, 14, 17 and 18]

Form of Application for Learner’s Licence Or Driving Licence Or Addition of a New Class of Vehicle Or Renewal of Driving Licence Or Change
of Address Or Name

To,

The Licencing Authority

RTO, GHAZIABAD

Services applying for (Please Tick mark against single or multiple service, wherever applicable)

Issue of New Learner’s Licence

Issue of New Driving Licence

Addition of Class of Vehicle to Driving Licence

Renewal of Driving Licence

Duplicate Driving Licence

Change / Correction of Address in Driving Licence

Change / Correction of Name in Driving Licence

1. Class of Vehicles (COV): Applicable for New Learner’s Licence or New Driving Licence

Motor Cycle Without Gear (MCWOG)

Motor Cycle With Gear (MCWG)

Light Motor Vehicle as Non Transport Vehicle (LMV NTV)

Invalid Carriage (vehicles for use by Divyang)

Light Motor Vehicle as Transport Vehicle

Medium or Heavy Goods or Passenger Vehicle as Transport Vehicle

E-Rickshaw

E-Cart

Others; which is not covered in any of the above categories including, Harvester, Excavator, Fork lift, Trailers,
Crane mounted vehicles, Agricultural tractor and power tiller, Tow trucks, Breakdown Van and Recovery
vehicles, Construction equipment vehicles

Explanation :-
1. Non - Transport Vehicles include Motor Cycle with or without sidecar for personal use, Mopeds, Three Wheeled vehicles for
personal use, Motor Car for personal use, Fork Lift;
2. Transport vehicle includes a public service vehicle, a goods carriage, an educational institution bus or private service vehicle;

3. Light motor vehicle includes a transport vehicle or omnibus the gross vehicle weight of either of which or a motor car or tractor or
road-roller the unladen weight of any of which, does not exceed 7,500 kilograms;
4.
Medium goods vehicle includes any goods carriage other than a light motor vehicle or a heavy goods vehicle;

5. Heavy goods vehicle includes any goods carriage the gross vehicle weight of which, or a tractor or a roadroller the unladen weight
of either of which, exceeds 12,000 kilograms.
2. Personal details of the Applicant (in Capital Letters)

Aadhar Card number

Details of Aadhar card, if already available with the
applicant.

Aadhar Card application number

Details of Aadhar application number if applied.

First Name Middle Name Last Name

NISHANT JATAV

Gender Date of Birth:

Male Female Transgender
(Tick )
16-08-1999
(dd/mm/yyyy)

Educational Blood Group

Qualification 10+2 or Equivalent O+

Email Mobile number

(optional) XXXXXX7159

Landline Number (optional)

3. Name of(Tick ) Father Mother Husband Guardian

First Name Middle Name Last Name

NARENDRA JATAV

4. Address (proof to be enclosed, in case of New Learner’s Licence or New Driving Licence or Change of Address)

Present Address (shall be printed on Licence) Permanent Address

House/Door/Flat No

VILLAGE ASALAT NAGAR POST VILLAGE ASALAT NAGAR POST

Street/Locality/Police Station
MURADNAGAR MURADNAGAR

Location/Landmark

Village/Town Asalat Nagar

SubDist/Taluk/Mandal Modinagar Modinagar

District Ghaziabad Ghaziabad

State Uttar Pradesh Uttar Pradesh

Pin code 201206 201206

5. In case of request for Addition of a Class of Vehicle in Transport Category, please fill the following:

Driving School Name

Enrollment number in the Driving School

Enrollment date in the Driving School

Certificate number issued by the Driving School

Certificate date as issued by the Driving School

Training period in the Driving School From date To date

6. Particulars of existing Licence (Learner’s or Permanent)

Licence Number

Class of Vehicle(s)

Name of the Licencing Authority which issued

the Licence

Validity Period From date To date

7. List of Documents attached (Please refer to the attached annexure and tick)
DECLARATION
I am willing to donate my organ/tissue in case of death YES/NO

I declare that the facts stated above and documents submitted are true and genuine to the best of my knowledge and belief. I also state thatI
have/ have notbeen disqualified from holding a Driving Licence.

Date: 12-06-2019 Signature of the Applicant

DECLARATION under sub-section (2) of section 7 of the Motor Vehicles Act, 1988
NISHANT JATAV
Shri/Smt./Kumari_______________________________________________________son/daughter of NARENDRA JATAV

who is a minor is under my care and I accept responsibility for his/her driving. If at a later date I decide not to accept

I shall inform the licensing authority in writing for the cancellation of the licence.I give my consent for his / her obtaining the

Name of the parent / guardian: NARENDRA JATAV

Relationship with the applicant: Father

Signature of the parent / guardian

 FOR OFFICE USE ONLY

1. The applicant is exempted from production of a medical certificate under Rule 6 of the Central Motor
Vehicles Rules, 1989; YES/NO

Learner’s licence may be issued.

2. The applicant is exempted from the Preliminary Test under sub-rule (2) of Rule 11 of the Central Motor
Vehicles Rules, 1989; YES/NO

Learner’s licence may be issued.

Preliminary Test to check adequate knowledge and

3. Date of Test Result ( ) Testing Authority
understanding of the matters namely traffic sighs, traffic
signals, duties of driver in case of his vehicle being involved in
an accident, or documents to be carried while driving etc,. Sub-
rule (1) of Rule 11 of the Central Motor Vehicles Rules, 1989
Pass / Fail / Absent/
Exempted

Driving Test (Rule 15 of the Central Motor Vehicles Rules, Date of Test
Result Pass / Fail
1989)

The Learner’s licence / Driving Licence is Issued Refused

Signature of licensing authority (or other person

authorised in this behalf)
 ANNEXURE

LIST OF DOCUMENTS TO BE SUBMITTED OR UPLOADED BY THE APPLICANT

Proof of Address and Age. (Select only one if the proof is common for Address and Age)

1. Aadhar Card

2. Electoral Roll

3. Life Insurance Policy

4. Passport

5. School Certificate

6. Birth Certificate

7.
Pay slip issued by any office of the State Government or Central Government or a local Body

8.
Affidavit sworn before an Executive Magistrate or Notary Public or First Class Judicial Magistrate

9. A certificate granted by a Registered Medical Practitioner not below the rank of Civil Surgeon as to the age of the
applicant

10. Any other document or documents as may be specified by State Government

Other documents to be enclosed or uploaded if applicable

1. Self Declaration for Physical Fitness in Form – 1

2. Medical Certificate in Form- 1A (to be provided if the applicant is applying for renewal and is above 40 years of
age or applying for Transport Licence)

3. Driving Certificate issued by Driving School or Establishments in Form 5

4. Parent or Guardian Declaration in case of applicant who is a minor

5. Photograph

6. Valid proof of passport andvisa (for International Driving Permit only)

7.
Proof of legal presence in India in addition to proof of residence in case of Foreigners

8. Other documents, if any

The copy of police complaint made(in case the Driving Licence was lost or mutilated or defaced or damaged, lost).
9.

10. For change of name -

(a) Existing name _______________________________

(b) Name to be changed as _______________________

(c) Documents enclosed:-

(i) Affidavit sworn before a First Class Judicial Magistrate or a Notary Public

(ii) Marriage certificate

(iii) Copy of newspaper advertisement

 CMV FORM 1 Appl No: 1672931219 Dt:12-06-2019
[See rule 5(2)]
Application –cum-declaration as to the physical fitness

1.Name of the applicant : NISHANT JATAV

2. Father's Name : NARENDRA JATAV

3.Permanent address :
VILLAGE ASALAT NAGAR POST MURADNAGAR
NEAR HANUMAN MANDIR
MURADNAGAR,GHAZIABAD,UP
201206
4.Temporary address :
Official address (if any) VILLAGE ASALAT NAGAR POST MURADNAGAR
NEAR HANUMAN MANDIR
MURADNAGAR,GHAZIABAD,UP
201206
5. (a) Date of birth : 16-08-1999
(b) Age on date of application : 19 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

( NISHANT JATAV )

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.
 CMV Form 1-A Appl No: 1672931219 Dt:12-06-2019
[See rules 5(1),(3),7,10(a),14(d), and 18(d)]
Medical Certificate

[ To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person
authorised in this behalf by the State Government referred to under sub-section (3) of Section 8]

1.Name of the applicant : NISHANT JATAV

2. Identification marks :

3. (a) Does the applicant, to the best of your judgment, suffer from any defect
of vision? If so, has it been corrected by suitable spectacles ? Yes / No

(b) Can the applicant, to the best of your judgment, readily distinguish the
pigmentary colours, red and green ? Yes / No

(c) In your opinion, is he able to distinguish with his eye sight at a distance
of 25 metres in good day light a motor car number plate ? Yes / No

(d) In your opinion, does the applicant suffer from a degree of deafness
which would prevent his hearing the ordinary sound signals ? Yes / No

(e) In your opinion, does the applicant suffer from night blindness ? Yes / No

(f) Has the applicant any defect or deformity or loss of member which would
interfere with the efficient performance of his duties as a driver? If so, give Yes / No
your reasons in details.

(g) Optional
(a) Blood group of the applicant (if the applicant so desires that the ..........................
information may be noted in his driving licence).

(b) RH factor of the applicant (if the applicant so desires that the ..........................
information may be noted in his driving licence).
Declaration made by the applicant in Form 1 as to his physical fitness is attached

Certificate of Medical Fitness

I certify that : -

(i) I have personally examined the Shri : NISHANT JATAV

(ii) that while examining the applicant I have directed special

attention to his / her distant vision;
(iii) while examining the applicant, I have directed special
attention to his / her hearing ability, the conditions of the arms,
legs, hands and joints of both extremities of the applicant; and
(iv) I have personally examined the applicant for reaction time,
side vision and glare recovery (applicable in case of persons
applying for a licence to drive goods carriage carrying goods of
dangerous or hazardous nature to human life.)

_____________________________________________________________________.

The applicant is not medically fit to hold a licence for the following reasons : -

______________________________________________________________________.

Signature :

1. Name and designation of the of Medical Officer

/ Practitioner

(Seal)
2. Registration Number of Medical Officer

Signature or thumb impression of the candidate

( NISHANT JATAV )

Date :

Note : -
1. The medical Officer shall affix his signature over the photograph affixed in
such a manner that part of his signature is upon the photograph and part
on the certificate.
2. Dumb persons without deafness may be granted a valid certificate
of driving licence for non-transport vehicle.
__________