Add Class W 728352018
Add Class W 728352018
Add Class W 728352018
To,
Affix Your
The Licensing Authority, Recent
ALA, KOLLAM Passport Size
Photo
License Details
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License No : 2/7644/2010
EN
Name of the Applicant
TM
J A Y A M O H A N C
Name of the Guardian
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J C H A N D R A N K U T T Y
A
I, hereby apply for the addition of the following class / classes of motor vehicle(s) to the attached Licence
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1. MOTOR CYCLE WITH GEAR
I enclose,
a) A Medical Certificate in Form 1
D
S
b) Application for Learner's Licence in Form 2
LE
Date ...................
H
The applicant has passed/failed in the test specified in Rule 15 of the central Motor Vehicles Rules,1989.The test was
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APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
[See Rule 3(a), 13]
LEARNER'S LICENCE
[Valid if and only if Signed by a Competent Authority ]
Licence No................................................................Date................................................
T
Photo
Blood Group-RH Factor :
EN
TM
Present Address Temporary Address / Official Address
VARSHA BHAVAN
R
THEVALLY.PO
KOLLAM-9
A
EP
Marks of Identification :
1: D
S
2:
LE
is licensed to drive throughout India as a learner subject to the provision of Rule 3 of the Central Motor Vehicles Rules, 1989 ,
IC
The holder of the licence has passed the medical test under Rule 5 and the preliminary test referred to in Rule 11(1) of the
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* Strike out whichever is inapplicable Signature and Designation of the Licensing Authority
LA
A
Warning :-
ER
The attention of the holder of this licence is drawn to Rule 3 of Central Motor Vehicles Rules, 1989 which prohibits him from
driving any motor vehicles unless he has besides him a person duly licensed to drive the vehicle and in every case,the vehicle
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carries 'L' plates both in the front and in the rear of the vehicle
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APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
Form -1
Application cum Declaration as to the Physical Fitness
See Rule 5(2)
T
EN
Present Address Temporary Address / Official Address
VARSHA BHAVAN
TM
THEVALLY.PO
KOLLAM-9
R
A
EP
DECLARATION
(a) Do you suffer from epilepsy or from sudden attacks of loss of consciousness or giddiness from any cause? YES / NO
D
S
(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
LE
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 vehicle fitted with an outside mirror on the YES / NO
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steering wheel side ) or with one eye,at a distance of 25 metres in good daylight (with glasses,if worn) a motor car
number plate?
H
VE
(c) Have you lost either hand or foot or are you suffering from any defect of muscular power of either arm or leg? YES / NO
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(d) Can you readily distinguish the pigmentary colours,red & green? YES / NO
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(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
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(g) Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be a source of
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I hereby declare that to the best of my knowledge and belief,the particulars given above and the declaration made
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.............................................
Signature or thumb impression of applicant
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 of information relating thereto
2) This declaration is to be submitted invariably with medical certificate in the formI-A
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APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
Form - 2
[See rule 10]
FORM OF APPLICATION FOR THE GRANT OR RENEWAL OF LEARNER'S LICENSE
To,
The Licensing Authority,
ALA, KOLLAM Affix Your
1. Full Name : JAYAMOHAN C Recent
2. Son/Wife/Daughter of : J CHANDRANKUTTY Passport Size
Photo
I hereby apply for a licence authorising me to drive as a learner,the following motor vehicle(s):-
T
EN
1. MOTOR CYCLE WITH GEAR
and Motor Vehicles to the following description :
TM
...............................Particulars to be furnished by the applicant...............................
3. Permanent Address(Proof to be Enclosed) 4. Temporary Address / Official Address(If any)
R
VARSHA BHAVAN
A
THEVALLY.PO
EP
KOLLAM-9
D
S
5. Date of Birth(Proof of Age to be enclosed) : 05/11/1987
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2 :
H
VE
R
TO
O
M
LA
A
ER
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8. Blood group - RH factor: ............
10. Particulars of any driving licence previously held by applicant. Whether it was cancelled and if so, for what reason?
11. Particulars of any driving licence previously held by applicant in respect of the description of vehicle to which the application.
has applied?
12. Have you been disqualified for holding or obtaining a driving licence or learner's licence ? If so,for what reasons?
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13. I enclose 3 copies of my recent photographs(passport size).
EN
14. I enclose medical fitness certificate dated ................................. issued by (doctor) ............................................................
TM
15. I have submitted along with my earlier application for learner's licence / I enclose the written consent of parent / guardian.
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( In the case of application being a minor)
A
16. I enclose driving certificate dated ............................................................ issued by ............................................................
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....................................................................................................................................(Name and address of driving school).
18. I am exempted from the medical test under rule 6 of Central Motor Vehicles Rules,1989.
IC
19. I am exempted from the preliminary test under rule 11(2) of Central Motor Vehicles Rules,1989.
H
VE
the applicant.
TO
O
The applicant is exempted from the Medical Test under rule 6 and the preliminary test under Central Motor Rule11(2) of the
LA
The applicant was tested with reference to Rule11(1) of the Central Motor Vehicles Rules 1989
He has passed Learner's Licence may be issued
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APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
CERTIFICATE FOR VISUAL STANDARDS FOR DRIVING
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EN
I have examined Shri/Smt. JAYAMOHAN C aged 31 and his/her visual standards are as follows:
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I. Visual Acuity
A B Sph Cyl Axis C
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Visual Acuity Unaided Corrected Binocular
A
Corrected
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RE
LE
D
S
LE
III. Squint............................................................
H
VE
IV.Field(Degree) Horizontal............................................Vertical............................................
V.Fundus:......................................................... RE ...........................................................LE
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TO
(Category-I means Non Transport Vehicles which include Motor Cycles, Motor Cars, etc.specified as such in Central Goverment
A
(Category-II means Transport vehicles which include Autorickshaws, Taxis, Stage Carriages, contract Carriages, goods carriages,
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Place : Seal
Date : 12-12-2018
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Certificate to be issued by an Ophthalmologist with a registered post graduate qualification in Ophthalmology.
The seal should contain the name, qualifications and register number of the Ophthalmologist.
Category I: Non-Transport Vehicles- includes Motor Cycles (MC), Owner driven Light Motor Vehicles (LMV)
(Vehicles not fitting criteria for category ll)
Category II: Transport Vehicles- Heavy Motor Vehicles (HMV), Commercial Passenger carrying vehicles, Goods carriers
(Any Category requiring issuance of a Badge)
I. Visual Acuity
1A. Unaided
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Category I: Binocular unaided visual acuity of 3/60 or better
EN
1B. Corrected
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Category I : Worse eye corrected visual acuity of 6/60 or better
Category II: Worse eye corrected visual acuity of 6/12 or better
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1C. Binocular Corrected
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Category I: Binocularly, with glass correction, the candidate should be able to read 6/12 or better.
EP
Category II: Binocularly, with glass correction, the candidate should be able to read 6/9 or better.
IV. Field
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V. Fundus
Undialted fundus examination unless otherwise indicated.To be recorded as WNL(Within noramal Limits) or any specific
LA
pathology noted.
Any Pathology that can affect night vision, field, acuity should be investigated and the clination should decide on fitness.
A
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