"FORM 2" Appl No.

1183595020 Dt:20-03-2020

[See rule 10]

FORM OF APPLICATION FOR THE GRANT OF LEARNER'S LICENCE
To
The Licensing Authority,
L.A. BOLPUR

I here by apply for a licence authorising me to drive as a learner, the following motor vechicle
MCWG
PARTICULARS TO BE FURNISHED BY APPLICANT
1. Full Name : KINKAR CHANDR GHOSH

2. Father's Name : ANUKUL CHANDR GHOSH

3. Permanent address : 4/32 PRANTIK TOWNSHIP, Taltor, BOLPUR

(Electoral Roll / Life Insurance Policy / Passport / Pay Slip issued by any SHANTINIKETAN,BIRBHUM,WB, 731235
office of the Central Government / State Government or a local body /
Any other documents as may be prescribed by the State Government /
Affidavit sworn before an executive magistrate or a First Class Judicial
Magistrate or a Notary Public

4. Temporary address / Official address, if any : 4/32 PRANTIK TOWNSHIP

Taltor
BOLPUR SHANTINIKETAN,BIRBHUM,WB
731235

5. Duration of stay at the present address : .......................................................

6(a). Date of birth : 20-08-1951
(Birth certificate / school certificate / affidavit sworn before an
Executive Magistrate or a First Class Judicial Magistrate or a
Notary public to be enclosed).
6(b). AADHAR NUMBER : NOT FURNISHED

7. Place of birth PASCHIM MIDNAPUR

: .......................................................
8. If place of birth out side India when migrated to India : ....................................................
9. Education Qualification : Graduate in Non Medical Sciences
10 Identification Mark(s) : 1.RED DARK SPOT ON RIGHT CHIK
2.CUT MARK ON RIGHT INDEX FINGER

11 Declaration of citizenship status

(i) If deemed Citizen or Citizen by Birth : INDIA
(Birth certificate and school certificate)
(In Support of Citizen ship as Indian to be enclosed)
(ii) If Citizenship is acquired by Descent / Registration
(In case Citizenship acquied by Descent, Birth Certificate,
land / property document of parent / in case of Citizenship acquired
by registration certificate to be enclosed)
(iii) If Citizenship by Naturalization
(Certificate of Naturalization and
Certificate of Registration to be enclosed)
(iv) If non-Indian Citizen

12 Blood Group : A+
RH(Rhesus) factor
13 I hold an effective driving licence to Drive: Motor Cycle /Light
Motor Vehicle / Transport Vehicle with effect from. ....................................................
14 Particulars of any driving licence previously held by applicant. Whether it was
cancelled and if so, for what reason ....................................................
15 Particulars of any learners licence previously held by applicant in respect of the
description of vehicle to which the applicant has applied. ....................................................
16 Have you been disqualified for holding or obtaining driving licence or learner's licence.
If so, for what reason. ....................................................
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
the case of applicant being a minor)

20 I enclose driving certificate dated ..................... issued by ............................................... (Name and address of the driving
school)
21 Have paid the fee of vide Token No. / Receipt

22 I am exempted from the medical test under rule 6 of the Central Motor Vehicles Rules, 1989.
23 I am exempted from the preliminary test under rule 11(2) of the Central Motor Vehicles Rules 1989.
* Strike out whichever is inapplicable
20-03-2020
Date............................

Specimen Signature or Thumb impression of Applicant.

Signature or Thumb impression of Applicant
1. ( KINKAR CHANDR GHOSH )

2.---------------------------------------

DECLARATION UNDER SUB-SECTION(2) OF SECTION 7 OF THE MOTOR VEHICLE ACT 1988

Not Applicable Not Applicable
Shri / Smt / Kumari ................................. Son / daughter of ........................................... 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 responsibility of his/her driving, I shall
intimate the licence authority in writing for the cancellation of the licence. I give my consent for his/her obtaining learner's
License.
Signature......................................................
Name and full address of the parent / guardian
Not Applicable
............................................................................
............................................................................
Relationship....................................................
Not Applicable

(To be signed in the presence of the licensing authority or person authorised in the behalf by the Licensing

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 Motor
Vehicles Rule, 1989.
Learner's licence may be issued.
The applicant was tested with reference of rule 11(1) of the Central Motor Vehicle Rules, 1989.
He has passed the test. Learner's Licence may be issued.
Learner's licence may be refused.

Signature of licensing authority or other

Person authorized in the 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 Licensing
Authority through Electronic Mail, if allowed by the concerned State Government / Union Territory
In such cases, the Licensing Authority shall scrutinse the application and intimate the applicant about the acceptance / any /
discrepancy.

In case the application is accepted, the applicant shall be intimated through Electornic mail to report to the Authority concerned on
a appointed date along with the documents for further verification, submission of application fee and examination of the applicant.
 CMV FORM 1 Appl No:1183595020 Dt:20-03-2020
[See rule 5(2)]
Application –cum-declaration as to the physical fitness

1.Name of the applicant : KINKAR CHANDR GHOSH

2. Father's Name : ANUKUL CHANDR GHOSH

3.Permanent address : 4/32 PRANTIK TOWNSHIP

Taltor
BOLPUR SHANTINIKETAN,BIRBHUM,WB
731235

4.Temporary address : 4/32 PRANTIK TOWNSHIP

Official address (if any) Taltor
BOLPUR SHANTINIKETAN,BIRBHUM,WB
731235

5. (a) Date of birth : 20-08-1951

(b) Age on date of application : 68 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

( KINKAR CHANDR GHOSH )

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.
 Appl No:1183595020 Dt:20-03-2020
CMV Form 1-A
[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 : KINKAR CHANDR GHOSH

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).
 Appl No:1183595020 Dt:20-03-2020

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 : KINKAR CHANDR GHOSH

(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

( KINKAR CHANDR GHOSH )

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.
__________