License Appl

8/12/2019 License Appl

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Online Application for Appointment with TN05 - CHENNAI(NORTH)

Commissioner of Transport

GOVERNMENT OF TAMILNADU

Booked Date

e-Acknowledgement Id

Name of the Candidate

Door Number

Street

Village / Town

District

Pincode

E.Mail

Purpose

RTO

Appointment Date

Appointment Time

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Enclosed Documents :

TN05/2014/T/216799/SA

SUDHEESH KARUVANTHODI

RAVINDRANATHAN K

34A

SOMASUNDARAM STREET

AGARAM

Chennai

600082

18-Mar-1990Date Of Birth :

23-Jul-2014

10-11

[email protected]

25-Jul-2014

TN05 - CHENNAI(NORTH)

No.9 Inner Ring Road

SASTRI NAGAR

KOLATHUR CHENNAI 600099

Learners License - Fresh License

S/O

Passport size photos 4 Nos.(1)

Passport(2)

Form 1(3)

Passport(4)



FORM 1[See rule 5 (2)]

Application-cum-declaration as to the physical fitness

1. Name of the Applicant SUDHEESH KARUVANTHODI

2. RAVINDRANATHAN K

3. Permanent Address

4. Temporary Address

Official address (if any)

5. a) Date of Birth 18/03/1990

b) Age on date of application

6. Identification marks

Declaration

Do you suffer from epilepsy, or from sudden attacks of loss of consciousness or giddiness from anycause?

Are you able to distinguish with each eye(or if you have held a driving licence to drive a motor vehiclefor a period of not less than five years and if you have lost, the sight ofone eye after the said period offive years and if the application is for driving a light motor vehicle other than a transport vehicle fittedwith 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

Have you lost either hand or foot or are you suffering from any defect of muscular power of either armor leg?

Yes / No

Can you readily distinguish the pigmentary colours,red and green?

Do you suffer from night blindness? Yes / No

Are you so deaf as to be unable to hear (and if the application is for driving a light motor vehicle, withor without hearing aid) the ordinary sound signal?

Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be asource of danger 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 declarationmade therein are true.

(Signature or thumb impression of the 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 information relating thereto.

2) This declaration is to be submitted invariably with medical certificate in Form 1-A.

e-Acknowledgement TN05/2014/T/216799/SA

Appointment Date 25/07/2014

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34A, SOMASUNDARAM STREET

AGARAM,CHENNAI

Chennai - 600082

34A SOMASUNDARAM STREET

AGARAM

- 600082

A BLACK MOLE ON THE RIGHT SHOULDER

A BLACK MOLE ABOVE THE RIGHT CHEEK

(1)

(2)

(a)

(b)

Yes / No

Yes / No

(c)

(d) Yes / No

(e)

(f)

(g)

Yes / No

Yes / No

S/O

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FORM 2[See rule 10]

FORM OF APPLICATION FOR THE GRANT OF LEARNER'S LICENCE

To

The Licensing Authority,

Space for

Passport size

Photograph

CHENNAI(NORTH)

1 MOTOR CYCLE WITHOUT GEAR

2 MOTOR CYCLE WITH GEAR

PARTICULARS TO BE FURNISHED BY APPLICANT

1. Full Name

2

3. Permanent Address

( Electoral Roll / Life Insurance Policy / Passport / Pay Slip Issued by any office of the CentralGovernment / State Government or a Local body / Any other document or documents as maybe prescribed by the State Government / Affidavit sworn before an Executive Magistrate or aFirst Class Judicial Magistrate or a Notary Public to be

4. Temporary address/ Official address, if any

6. Duration of stay at the present address

5. Date of birth

( Birth certificate / School certificate / affidavit sworn before an ExecutiveMagistrate or a First Class Judicial Magistrate or a Notary Public to be

7. Place of birth

8. If place of birth outside India, when migrated to India

9. Educational Qualification

10. Identification mark(s)11. Declaration of citizenship status

(i) If deemed Citizen or Citizen by Birth

12. Blood Group

RH (Rhesus) factor

SUDHEESH KARUVANTHODI

RAVINDRANATHAN K

18/03/1990

A1+

A BLACK MOLE ON THE RIGHTSHOULDER,A BLACK MOLE ABOVE THERIGHT CHEEK

(Any one of the following in support of Citizenship as Indian to be enclosed) :

a) Proof of birth in India from Municipality or Registrar of Births and Deaths;

b) School leaving certificate / Secondary School Certificate showing nationality / place of birth;

c) Passport showing place of birth / citizenship / nationality;d) Certificate of Nationality / citizenship issued by District Magistrate or any other Administrative Officer;

e) Residency Permit / domicile certificate issued by State Government;

f) Grant of patta / lease of property by the Central / State Government;

g) Refugee Registration Card pertaining to the period 1947-1950;

h) Certificate of SC / ST / OBC.

(ii) If Citizenship is acquired by Descent / Registration __________________________

(in case Citizenship acquired by Descent, Birth Certificate, land/property document of parent/in case of citizenship acquired byregistration, certificate to be enclosed)

(iii) If Citizenship by Naturalization

(Certificate of Naturalization and Certificate of Registration to be enclosed)

(iv) If non-Indian Citizen ___________________________________

(Valid passport or other travel documents and such other document or authority as may be prescribed by law to be

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__________________________________ 34A, SOMASUNDARAM STREET

__________________________________ CHENNAI

Chennai - 600082 __________________________________

__________________________________ 34A SOMASUNDARAM STREET

__________________________________ AGARAM

__________________________________ - 600082

__________________________________

__________________________________

__________________________________

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S/O

I hereby apply for a licence authorising me to drive as a learner, the following motor vehicle(s):-

e-Acknowledgement ID TN05/2014/T/216799/SA

Appointment Date 25/07/2014

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14. Particulars of any driving licence previously held by applicant. Whether it wascancelled and if so, for what reason

15. Particulars of any learners licence previously held by applicantin respect of thedescription of vehicle to which the applicant has applied

16. Have you been disqualified for holding or obtaining driving licence of learner'slicence. If so, for what reasons

17. I enclose three copies of my recent photograph

(Passport size photograph)

18. I enclose medical fitness certificate dated____________ issued by __________________ doctor

19. I have submitted along with my earlier application for Learner's licence / I enclose the written

consent of Parent / guardian (In case of applicant being minor)

21. I have paid the fee of Rs______________

23.I am exempted from preliminaryl test under rule 11(2) of the Central Motor Vehicle Rules,1989.

Date ________________

22. I am exempted from the medical test under rule 6 of the Central Motor Vehicle Rules, 1989.

* Strike out whichever is inapplicable

Signature or thumb impression of Applicant

2.___________________________

1.___________________________

Specimen signature or thumb impression of Applicant

Shri/Smt/Kumari ________________ ___________________ Son/Daughter of ___________________ who is a minor is under mycare and I accept responsibility for his/her driving. If at a later date I decide not to accept responsiblity for his/her driving I shallintimate the licensing authority in writing for the cancellation of the licence. I give my consent for his/her obtaining learner's licence.

Signature___________________________

Name and full addres of the Parent / guardian

Relationship __________________

20. I enclose driving certificate dated____________ issued by _________________________________________________ (nameand address of the driving school)

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

Declaration under sub-section (2) of section 7 of the Motor Vehicles Act 1988

13. I hold an effective driving licence to drive : Motor Cycle / light motor vehicle / transport vehicle with effect from

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For Official use

The applicant is exempted from the medical test under rule 6 and the preliminary test under rule 11(2) of the Central MotorVehicles Rules, 1989 Learner's licence may be refused.

Signature of licensing authority or othe rPerson authorized in this behalf

* Strike out whichever is inapplicable

Note: The application along with the scanned copies of the required documents may also be sent to the concerned LicensingAuthority through Electronic mail, if allowed by the concerned State Government / Union Territory Administration.

The applicant was tested with reference to rule 11(1) of the Central Motor Vehicles Rules, 1989.

He/She failed in the test.(Reasons should be specified). Learner'sLicence may be refused.

In such cases, the Licensing Authority shall scrutinize the application and initimate the applicant about the acceptance / anydiscrepancy.

In case the application is accepted, the applicant shall be intimated through Electronic mail to report to the Authority concerned onan appointment date with the documents for further verification, submission of application fee and examination of the applicant.

He/She has passed the test. Learner's Licence may be issued.

License Appl

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