Professional Documents
Culture Documents
Commissioner of Transport
Online Application for Appointment with TN39Z - AVINASHI
e-Acknowledgement Id
: TN39Z/2016/T/871343/GT
Booked Date
: 08-Mar-2016
: GOVINDARAJ R
Date Of Birth
: 03-Jun-1997
S/O
: RANGASAMY
Door Number
: 5/149
Street
: RAMIYAMPALAYAM
Village / Town
: THANDUKARENPALAYAM CHEYUR PO
District
: Tirupur
Pincode
: 641655
Purpose
E.Mail
RTO
: TN39Z - AVINASHI
Palankaraipudhur Road
Kaikattipudur
Coimbatore
Appointment Date
: 10-Mar-2016
Appointment Time
: 10-11
Enclosed Documents
641654
(1)
School Certificate
(2)
(3)
Form 1
(4)
RationCard
e-Acknowledgement
: TN39Z/2016/T/871343/GT
Appointment Date
: 10/03/2016
FORM 1
[See rule 5 (2)]
Application-cum-declaration as to the physical fitness
1. Name of the Applicant
GOVINDARAJ R
2. S/O
RANGASAMY
3. Permanent Address
5/149, RAMIYAMPALAYAM
THANDUKARENPALAYAM CHEYUR PO,AVANASHI TK TIRUPUR
Tirupur - 641655
4. Temporary Address
Official address (if any)
5/149 RAMIYAMPALAYAM
THANDUKARENPALAYAM CHEYUR PO
- 641655
5. a) Date of Birth
b) Age on date of application
:
:
03/06/1997
6. Identification marks
Declaration
(a) Do you suffer from epilepsy, or from sudden attacks of loss of consciousness or giddiness from any
Yes / No
cause?
(b) Are you able to distinguish with each eye(or if you have held a driving licence to drive a motor vehicle
Yes / No
for a period of not less than five years and if you have lost, the sight ofone 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
(c) Have you lost either hand or foot or are you suffering from any defect of muscular power of either arm
Yes / No
or leg?
(d) Can you readily distinguish the pigmentary colours,red and green?
Yes / No
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
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.
e-Acknowledgement ID
: TN39Z/2016/T/871343/GT
Appointment Date
: 10/03/2016
FORM 2
[See rule 10]
FORM OF APPLICATION FOR THE GRANT OF LEARNER'S LICENCE
To
The Licensing Authority,
Space for
AVINASHI
Passport size
Photograph
I hereby apply for a licence authorising me to drive as a learner, the following motor vehicle(s):1 MOTOR CYCLE WITH GEAR
GOVINDARAJ R
__________________________________
RANGASAMY
__________________________________
5. Date of birth
( Birth certificate / School certificate / affidavit sworn before an Executive
Magistrate or a First Class Judicial Magistrate or a Notary Public to be
6. Duration of stay at the present address
7. Place of birth
8. If place of birth outside India, when migrated to India
9. Educational Qualification
03/06/1997
__________________________________
5/149,
RAMIYAMPALAYAM
__________________________________
AVANASHI TK TIRUPUR
__________________________________
Tirupur - 641655
__________________________________
5/149
RAMIYAMPALAYAM
__________________________________
THANDUKARENPALAYAM
CHEYUR
__________________________________
641655
PO
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
A SCAR STOMACH,A MOLE AT RIGHT
__________________________________
DOWN EYE
__________________________________
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 applicantin respect of the
description of vehicle to which the applicant has applied
16. Have you been disqualified for holding or obtaining driving licence of learner's
licence. If so, for what reasons
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Signature___________________________
Name and full addres of the Parent / guardian
Relationship __________________
______________________________________
(To be signed in the presence if the licensing authority or person authority in this behalf by the licensing authority)