3616272819 Dt:13-10-

FORM 2 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

SRTO,TRIPUNITHURA

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)

Adapted Vehicle (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. Not Furnished

Aadhar Card application number

Details of Aadhar application number if applied.

First Name Middle Name Last Name

POOJ
A R NAIR

Gender Femal Transgend Date of Birth: 01-12-1995

Male e er
(Tick ) (dd/mm/yyyy)

Educational Diploma in any

Qualification Discipline Blood Group O+

Email Mobile number XXXXXX6593

(optional)

Landline Number
(optional)

3. Name of(Tick
) Father Mother Husband Guardian

First Name Middle Name Last Name

RAVINDRA NATH NAIR

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 IX/379 GOKULAM SMP B109 DUGGAL

No ROAD APARTMENT

WARD NO 2 NEAR
Street/Locality/Police WALMIKI
Station KANAYANNUR (CT) MANDHIR

Location/Landm KANAYANNUR,ERNAKULAM,K Mehrauli,South

ark L Delhi,DELHI

Village/Town Kanayannur (CT)

Kanayann
SubDist/Taluk/Mandal ur Mehrauli

Ernakula
District m South Delhi

State Kerala Delhi

Pin code 682301 110030
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

To
Training period in the Driving School From date 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

To date
Validity Period From 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 YES/N
of death O

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: 13-10-2019 Signature of the Applicant

under sub-section (2) of section 7 of the Motor

DECLARATION Vehicles Act, 1988
RAVINDRA NATH
POOJA R NAIR NAIR
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
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: RAVINDRA NATH NAIR
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;

Learner’s licence may be issued. YES/NO

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

Learner’s licence may be issued.

Testing
3. Preliminary Test to check adequate knowledge and Date of Test Result ( ) 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 Date of Test Result Pass / Fail
Rules,
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

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

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

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 Appl No: 3616272819 Dt:13-10-
1 2019
[See rule
5(2)]
Application –cum-declaration as to the physical fitness

1.Name of the applicant : POOJA R NAIR

2. Father's Name : RAVINDRA NATH NAIR

3.Permanent address : B109 DUGGAL APARTMENT

WARD NO 2 NEAR WALMIKI MANDHIR
Mehrauli,South Delhi,DELHI
110030

4.Temporary address :IX/379 GOKULAM SMP ROAD

Official address (if any) KANAYANNUR (CT)
KANAYANNUR,ERNAKULAM,KL
682301

5. (a) Date of birth : 01-12-1995

(b) Age on date of
application : 23 years
6. Identification marks :

Declaration :

(a)Do you suffer from epilepsy, or from sudden

attacks of loss of consciousness or giddiness Yes / No
from any cause ?

(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 Yes / No
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
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?
Yes /
(c) Have you lost either hand or foot or are you suffering No
from any defect in movement, control or muscular power of
either
arm or leg ?

(d) Can you readily distinguish the pigmentary s

colours, red and green ?

(e)Do you suffer from night blindness ?

(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 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 to the public, if
 o, give details? Yes / No

Yes / No

Yes / No

Yes / No

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

( POOJA R NAIR )

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 Appl No: 3616272819 Dt:13-10-
1-A 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]

: POOJA R
1.Name of the applicant NAIR

2. Identification marks :

(e)In your
opinion,
3. (a) Does the applicant, to the best of your judgment, does the
suffer from any defect of vision? If so, has it been applicant
corrected by suitable spectacles ? suffer
from night
(b)Can the applicant, to the best of your judgment, blindness
readily distinguish the pigmentary colours, red and ?
green ?
(f)Has the
(c)In your opinion, is he able to distinguish with his eye applican
sight at a distance of 25 metres in good day light a t any
motor car number plate ? defect
or
(d)In your opinion, does the applicant suffer from a deformit
degree of deafness which would prevent his y or loss
hearing the ordinary sound signals ? of
 member which would interfere with the efficient
performance of his duties as a driver? If so, give your
reasons in details.

(g)Optional Yes /
(a)Blood group of the applicant (if the applicant so No
desires that the information may be noted in his
driving licence).
Yes /
(b)RH factor of the applicant (if the applicant so No
desires that the information may be noted in
his driving licence).
Yes /
No

Yes /
No

Yes /
No

Yes /
No

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

..........................
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 Smt/Kum : POOJA R NAIR

(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

( POOJA R NAIR )

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.
__________
 CERTIFICATE FOR VISUAL STANDARDS FOR
DRIVING (see instructions overleaf before filling
up the certificate)

23
POOJA R NAIR years
I have examined ............................................................. aged
Smt/Kum : ........ ………………
and his/her visual standards are as follows:

Photograph of the candidate

(To be signed upon by the Ophthalmologist)

1. Visual
Acuity

C.
Visual A. B. Sph Cyl Axis
Binocular
Unaide
Acuity d Corrected
Corrected

RE

LE

II Night
blindness

III Squint
IV
Field(Degrees)Horizont ................................................ Vertical
al ........ …………......................
V Fundus: RE ……………………................LE……………...............
………………................... ….....…
Any other significant ocular morbidity ………………………………....................................................
Candidate is Fit/Unfit to drive a Category I/II vehicle.

Unfit due to criteria …….......................................………………..mentioned above.

(Category-I means Non Transport Vehicles which include Motor Cycles, Motor Cars, etc.
specified as such in Central Government Notification No.S.O.1248(E)dated 5th November
2004 as non-transport
(Category-II means Transport vehicles which include Autorickshaws, Taxis, Stage
carriages, Contract Carriages, Goods carriages, Private Service Vehicles etc. specified as
such in the said Notification.)
 Signature of
Signature of the candidate: Ophthalmologist

Place: SRTO,TRIPUNITHURA Seal

Date: 13-10-2019
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.

Visual Standards criteria for driving

Category I: Non-Transport Vehicles – includes Motor Cycles (MC), Owner driven Light Motor
Vehicles (LMV) (Vehicles not fitting criteria for category II)

Category II: Transport Vehicles – Heavy Motor Vehicles(HMV), Commercial Passenger

carrying vehicles, Goods carriers (Any category requiring issuance of a Badge)

1.Visual Acuity
1A. Unaided
Category Binocular unaided visual acuity of 3/60 or better
IB. Corrected
Category Worse eye corrected visual acuity of 6/60 or better
Category Worse eye corrected visual acuity of 6/12 or better
IC. Binocular
Catego Binocularly, with glass correction, the candidate should be able to read

ry 6/12 or better : Binocularly, with glass correction, the candidate should

be able to read 6/9 or better

Catego
ry
II Night blindness*
Presence of night blindness is not acceptable for both
category II and I *This being a symptom is recorded as
reported by the patient

III Manifest Squint

Catego Squint with visual acuity as in criteria I acceptable

ry Any squint is unacceptable for Category II

Catego
ry
IV Field
Binocular field checked by confrontation method

Catego Horizontal field of vision o f 120 degrees and vertical

ry of 40 degrees Horizontal field of vision of 180 degrees

Catego and vertical 40 degrees

ry
V Fundus
Undialted fundus examination unless otherwise indicated. To be recorded as WNL (Within
Normal Limits) or any specific pathology noted.

Any pathology that can affect night vision, field, acuity should be investigated and the clinician
should decide on fitness.

Colour vision problems by itself are not an impediment to driving.