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    1) Aksh Vikramkumar Jain is applying for an International Driving Permit to drive Category L1, L2, and M1 vehicles in other countries. 2) He provides personal details like name, father's name, date of birth, address, and medical details in the application. 3) He declares that he does not suffer from any conditions like epilepsy, blindness, deafness that would impair his ability to drive. He affirms that the information provided is true to the best of his knowledge.

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    1) Aksh Vikramkumar Jain is applying for an International Driving Permit to drive Category L1, L2, and M1 vehicles in other countries. 2) He provides personal details like name, father's name, date of birth, address, and medical details in the application. 3) He declares that he does not suffer from any conditions like epilepsy, blindness, deafness that would impair his ability to drive. He affirms that the information provided is true to the best of his knowledge.

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    1) Aksh Vikramkumar Jain is applying for an International Driving Permit to drive Category L1, L2, and M1 vehicles in other countries. 2) He provides personal details like name, father's name, date of birth, address, and medical details in the application. 3) He declares that he does not suffer from any conditions like epilepsy, blindness, deafness that would impair his ability to drive. He affirms that the information provided is true to the best of his knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    83 views3 pages

    Form PDF

    Uploaded by

    Aksh Jain
    1) Aksh Vikramkumar Jain is applying for an International Driving Permit to drive Category L1, L2, and M1 vehicles in other countries. 2) He provides personal details like name, father's name, date of birth, address, and medical details in the application. 3) He declares that he does not suffer from any conditions like epilepsy, blindness, deafness that would impair his ability to drive. He affirms that the information provided is true to the best of his knowledge.

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    FORM 4-A Appl.

    No: 1866401619 Dt:27-06-2019


    [See Rule 14(2)]
    FORM OF APPLICATION FOR ISSUE OF INTERNATIONAL DRIVING PERMIT TO DRIVE
    A MOTOR VEHICLE IN OTHER COUNTRIES

    To
    The Licensing Authority,
    RTO,MUMBAI CENTRAL
    .................................................

    .................................................

    I apply for an International Driving Permit to enable me to drive vehicles of the following categories:-

    CATEGORIES OF VEHICLES FOR WHICH THE PERMIT IS APPLIED FOR

    (A) Motor Cycles Category L1 and Category L2;


    (B) Motor vehicles other than those in category (A) above, having a permissible maximum mass/weight not exceeding
    3,500 kg. (7700 lb) and not more than eight seats in addition to the driver's seat in Category M1;

    PARTICULARS TO BE FURNISHED BY APPLICANT

    1. Name : AKSH VIKRAMKUMAR JAIN


    .........................................................................................

    2 Father's Name : VIKRAMKUMAR JAIN


    .........................................................................................

    RAJASTHAN
    3. Place of Birth and Country (Proof to be : .........................................................................................
    enclosed)
    4. Address :

    (a) Present : A/8 ANAND NAGAR GRD FLR FORJEET STREET


    OPP BHATIA HOSPITAL
    MUMBAI,MUMBAI,MH
    400036

    (b) Permanent : A/8 ANAND NAGAR GRD FLR FORJEET STREET, OPP BHATIA
    HOSPITAL, MUMBAI,MUMBAI,MH, 400036

    5. Date of Birth (Proof to be : 28-06-1999

    6. Educational Qualification : Not Specified / NA

    7. Identification marks :

    8. Blood Group/RH factor : B+

    9. Have you previously held International :


    Driving Permit ? If so give details

    10. Particulars and date of every :


    conviction which has been ordered to be
    endorsed on any driving licence held by
    the applicant.
    11. Have you been disqualified for : .......................................................................................................
    obtaining driving licence to drive ? If so,
    for what reason ?

    12. Have you been subjected to a driving : .......................................................................................................


    test as to your fitness or ability to drive a
    vehicle in respect of which a driving
    licence is applied for ? If so, give the
    following details
    Date of Test Testing Authority Result of Test

    1)
    2)
    3)
    4)

    13. I enclose three copies of my recent passport size photograph.


    MH01 20170041648
    14. I enclose the copy of driving licence No. ..................................................
    dated : 04-09-2017 RTO,MUMBAI CENTRAL
    .......................... issued by ............................................................................valid upto: 03-09-2037

    15. I enclose a medical certificate in Form 1A.

    16. I have paid the fee of Rs. .................................................

    I hereby declare that the particulars given above are true to the best of my knowledge and belief.

    27-06-2019
    Date: .................................. Signature / Thumb Impression of Applicant.

    * Strike out whichever is inapplicable.


    CMV FORM 1 Appl No: 1866401619 Dt:27-06-2019
    [See rule 5(2)]
    Application –cum-declaration as to the physical fitness

    1.Name of the applicant : AKSH VIKRAMKUMAR JAIN

    2. Father's Name : VIKRAMKUMAR JAIN

    3.Permanent address : A/8 ANAND NAGAR GRD FLR FORJEET STREET


    OPP BHATIA HOSPITAL
    MUMBAI,MUMBAI,MH
    400036

    4.Temporary address : A/8 ANAND NAGAR GRD FLR FORJEET STREET


    Official address (if any) OPP BHATIA HOSPITAL
    MUMBAI,MUMBAI,MH
    400036

    5. (a) Date of birth : 28-06-1999


    (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


    ( AKSH VIKRAMKUMAR JAIN )

    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.

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