Application Form for

a Learner Permit D201

Please read accompanying guidance notes before
completing this form. Please complete this form in
block capitals using a black ballpoint pen. Please place
an X in the appropriate boxes e.g. Please do not
photocopy this form as it may reduce its quality and
result in your application being delayed or rejected.

Part 1: Personal Details (See Part 1 of accompanying guidance notes) *Mandatory field

1. Have you previously held a learner permit and/or driving licence in Ireland?* Yes No

If yes, which one? Learner Permit Driving Licence

Driver number* (if known)

(You

will find this on Field 5 of the paper licence or Field 4d on a plastic card licence.)

Other
2. Title Mr
Mrs Miss Ms (please specify)

Name to appear on the permit. Acceptable photo ID must be provided in this name. Refer to list 1 on page 2 of guidance notes.

3. First name(s)*

4. Surname*
As it appears on your birth certificate

5. Full name

6. If your surname has changed since your last learner permit issued please indicate the reason

Marriage/Civil partnership Deed Poll Use of Irish name Divorce/Separation

Previous names
Proof of address provided must match exactly the address given below. Please refer to list 2 on page 2 of the guidance notes.

7. Address 1*

Address 2

Town*
Official
County/City* Eircode Use
If aged 70 or over, or if your current learner permit expires on the eve of your
8. Date of birth* 70th birthday a valid medical report will be required.

Day Month Year

9. Gender* Male Female

10. PPSN* Original proof PPSN must also be provided. See list 3 on page 2 of the Guidance Notes.

If born in Republic of Ireland, please state county. If born outside the Republic of Ireland, please state Country.

11. Place of birth*

12. Mobile no.* Landline

Email address*

(The NDLS will use these contact details to contact you in the event of issues with your application, dispatch of your licence and future renewal reminders.

October 2016
 Part 2: Learner Permit Details (See Part 2 of accompanying guidance notes) *Mandatory field

13 (a). Application type*: First time learner permit application

Renewal of Learner permit.

Please see option 1 of checklist
Please see option 2 of checklist

Add/remove a category.
Replace a lost or stolen learner permit
Please see option 3 of checklist Please see option 4 of checklist

Personal detail change. GROUP 1 Replace a damaged permit GROUP 2

Please see option 5 of checklist GROUP 1 Please see option 6 of checklist GROUP
Licence Description of Licence Description
Have a full licence and applying forVehicle
a Other(Reason):
learner permit in a different categoryDescription
Licence
Category of Licence
Category Descriptio
Vehicle
Category
Please see option 7 of checklist
Vehicle Category Vehicle
GROUP 1 GROUP 2
M 50c.c.
Moped C1 7,500kg Small Truck –
13(b). If your application relates to the requirement
MGROUPto sit1a
45KmH
50c.c.
Moped GROUPC1 2 7,500kg Small Truck
driving test/driver training following a period of
Licence 45KmH
Description of Licence Description of
disqualification please provide periodCategory A1 Vehicle
125c.c.
Motorcycle up to 125cc
Category C Vehicle Large Truck –
Licence of disqualification From To 2 of
A1GROUP 111KW
Description of
125c.c.
Motorcycle
Licence
up to 125cc 2
GROUP
Description
C Large Truck
GROUP 1Category Vehicle 11KWGROUP 1 Category
GROUP Vehicle GROUP
Small
2
Details of any condition relating 1M
to the disqualification.
Moped GROUP 1
50c.c.
C1 Small Truck – less than 7,500 kg Truck a
GROUP
GROUP GROUP 2 EC1 7,500kg
Licence Description of 45KmH
Licence Description of 12,000kg
25KW Small Truck more than 12
14.* Please GROUP
indicate
Licence here 1theDescription M Category
categoryA1orofcategories that you
50c.c.
Moped
ALicence
wish to GROUP
Vehicle
0.16KW/Kg
apply for.
Licence 2
Description of Small
Category
DescriptionC1of
Truck – less than 7,500 kgDescription
Licence 7,500kg
more than 1
EC1
Vehicle 12,000kg
up toMotorcycle over C125cc
45KmH 25KW
Motorcycle 125cc
125c.c.
0.16KW/Kg Large Truck – over 3,500 kg
For aCategory
Licence GROUP
definition 1 Vehicle
of the categories Description
please of
refer to page Licence
A
Category Category
4 of the guidance note
11KW
Licence GROUP
Description
Vehicle
Motorcycle 2
of
Vehicle
over 125cc
Description of EC Licence
Category Large Truck a
Descriptio
Vehicle
M A1 Moped 50c.c.
C1
Motorcycle up to 125cc
125c.c. Small Truck – less than 7,500 kg
C 7,500kg
Large TruckTruck
– over 3,500 kg – noLarge
Licence Category DescriptionVehicle of Category
Licence
45KmH
11KW
Category Vehicle
Description of
Vehicle EC
Small
Category and Trailer Vehicle Truck
EC1 12,000kg

Category Vehicle
GROUP 1 Moped
25KW
Category Vehicle
GROUP 2of kg. SmallD1
more
Truck
than
and
12,000
Trailer
kg
– no Small
Group M
1 Required Notes A1 Group 1 M11KW Required up toGroup 2 7,500kg
up toRequired –Notes C1 Group kg2kg kgRequiredSmallBus –
0.16KW/Kg
Licence Description
50c.c.
of Licence
125c.c.
C1
Motorcycle 50c.c.
Moped
125cc Description C3,500 Large Truck – over 3,500 Truck
A 45KmHoverVehicle
Motorcycle 125cc EC1 Small Truck12,000kg less than 7,500 1+16 7,500kg

CategoriesM pleaseVehicle
45KmH
Categories B25KW please 3,500kg
50c.c.Categories ECtick moreLarge thanCategories
D1 12,000
Truck and pleaseSmall
Trailer tick Bus –
Category tick 50c.c. Moped A
MCategorytick3,500kg
0.16KW/Kg
C1
1+8 Moped
Max Vehicle
Vehicle
8 up please
passengers
7,500kgto 3,500
Small kg.
Truck – less C1
than 7,500 kg 1+16 7,500kg Small Truc
45KmH B Motorcycle over 45KmH 125cc
EC1
Small Truck and Trailer – no
Large Bus –
M
Licence A1 45KmH
50c.c.
Moped
Description of A125KW C1
Licence C125c.c. 1+87,500kg
Max Small
Description
Motorcycle Truck
8 passengers
EC
upLarge
to–of less
125cc than–7,500
12,000kg
Large
more D kg Truck
Cthan 12,000and Trailer
kg Large
Motorcycle up to 125cc Truck over 3,500 kg LargeTruck
125c.c.
11KW
A
0.16KW/Kg
Motorcycle
Vehicle up
11KW
over 125cckg.
to 3,500 D1 1+16 note. AllSmall D Bus – max. 16 passengers passengers Bus
Category
M A145KmH
50c.c. Vehicle
GROUP
Moped 1
125c.c.
Motorcycle B up to 125cc A1
EB 1+8 Category
C1 C125c.c. Vehicle
GROUP
Motorcycle
Small Truckup 2to
Large
– 125cc
less
Please
Truck
than –
7,500 over kg C
3,500 kg Large Truc
GROUP 1 ECGROUP 2
3,500kg
11KW Max up 11KW
8 passengers Car
7,500kg
and Trailer
D1Small Truck applications Largefor Truck and Trailer passengers
8 Small
SmallBus an
and Small Bus – max. 16 passengers Truck
A1 125c.c.
11KW Motorcycle GROUPup to 125cc
B1 3,500kgEB C Vehicle EC1
to 3,500 kg. Large Truck
Car and Trailer
12,000kg
– over1+16
DGROUP 3,500 2and
group kgTrailer
2 ED1 Large
EC1
– noBus – more12,000kg
than
12,000kg

M
AM 50c.c.
25KW B 1+8

C1
Max 8 passengers
25KW C more
Small than
D1 – less 1+16 Truck12,000
categories kg
Trailer
LargeED1
Small EC1
Bus –
passengers
Bus––max.
D
no
more16 passengers
than 812,000kg
Small
than
more Bus
12,000
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than 1ka
A1
Licence 125c.c. Moped
Description
Motorcycle
0.16KW/Kg
upofto 125cc EB A C Vehicle
Licence upEC1to
0.16KW/Kg 7,500kg kg. Small 12,000kg
3,500 Description
Large Truck
D ofover than
3,500 7,500
kgbe kg
12,000kg
than
more 12,000
than
ALicence
45KmH
11KW Description
25KW Motorcycle B over
of 125cc 3,500kg Car and Trailer
Licence25KW Tractors Small
Motorcycle and Truck
over
Work and
125ccTrailer
Description
more than –
must
of
12,000no kg
Small
passengers Bus and Trailer – no more
W Category
A EC1
Category Category Vehicle Please refer to 1+8
Max 8 passengers
0.16KW/Kg
Vehicle ED1 Truck 12,000kg ED
ALicence
0.16KW/Kg
Description of 125cc EC Licence
12,000kg
Motorcycle Large accompanied
Description and of by
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LargeBusTruckan
25KW Vehicle
accompanying
EB
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0.16KW/Kg
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Category Motorcycle upVehicle
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125cc C
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M
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M 45KmH Moped
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and
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16 D1
kg passengers Small Bus –
B
50c.c.
45KmH Vehicle
notes
Moped up
W to 3,500 kg.
B 3,500kg Small Truck
1+16 7,500kg Small Truck
ED and Trailer – no one – less
month than
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12,000 kg1+16
kg Trailer
and
3,500kg
EC1
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M 25KW 50c.c.
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8topassengers C1Work Max
1+8 Vehicle
81+16 upTruck
passengers and
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to 12,000
3,500 Trailer
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application. 16
Truck – less than 7,500 kg passengers
45KmH relation B D1 Tractors and
1+8
B0.16KW/Kg Vehicle up
W to 3,500 kg. 3,500kg more than kg 1+16

A1
3,500kg
Vehicle C Vehicles Max Small BusEDLarge
8 passengers – max. Bus
16 – more
passengers than
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D
Bus8 and Trailer Large Bus –
125c.c. up to 3,500 kg. 1+8
A
B
125c.c.
A13,500kg Motorcycle
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overto125cc
application
Max
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8 passengers
up to 125cc DC 1+16 Large TruckLarge– over 3,500
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A2 A11+8
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C1 passengers
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requirements W EBD1
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toMotorcycle kg. up to 125cc C CarSmall Bus – max. Large16 passengers
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B EB3,500kg Vehicle 11KWupCar 3,500
and Trailer and Trailer
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– Trailer
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D
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– no more Small Bus a
1+8
EB 25KW Max 8 passengers
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12,000kg
and
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than 12,000 kg guidance 12,000kg

D1 Large
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more
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and
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notes and Trailer
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in kg ED1 – –
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A
0.16KW/Kg
Car
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25KW
andup Trailer
to 3,500 kg. D ED1
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Bus – max. 16 passengers 12,000kg
B A 3,500kg Motorcycle
0.16KW/Kg over
25KW Tractors 125cc
Motorcycle and Work
over 125cc
1+16
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Tractors and
passengers
12,000kg
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more
than than
12,000 – 12,000
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kg tomore
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A W A 1+8 Max 8 passengers
0.16KW/Kg W EC ED1 ED C1E Large
12,000kg
Truck and Bus
Trailerrequirements ED D1E Large Bus a
EB Car and TrailerMotorcycle
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Vehicles
Large andLarge
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W ED1 EDEC Small Bus and Trailer ED Large Bus
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Bus and and Trailer
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W ED than 12,000
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D1
EB
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On receipt Vehicles
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Small
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Bus –
Bus and
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Small 16 passengers
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more No
W B 1+8 Max3,500kg
8 passengers ED1
ED D1 12,000kg
Large Bus and Small Bus – max. 16 passengers
Trailer
Vehicles1+8
MaxVehicle
8 up to
passengers 3,500 kg. than1+1612,000
Large Bus Large kg
– moreBus than
If ‘Yes’,Bplease provide 1+8details below: –8
3,500kg
D more than 8
W Tractors and Max Work8 passengers D passengerspassengers
ED D Large Bus and Large
TrailerBus – more than 8
EB EB Vehicles
Car and Trailer
Issuing country Car and Trailer Small Bus and passengers
Trailer – noTrailer
more – no more
EB ED1 ED1
12,000kg Small Bus and
Car and Trailer than12,000kg
12,000than kg
Small Bus kg and Trailer – no more
ED1 12,000kg
12,000
W Driving licence Tractors
no. and Work and Work
Tractors than 12,000 kg
W Vehicles Vehicles ED ED Large Bus Large and Trailer
Tractors and Work Bus and Trailer
W ED
16. If your learner permit was lost or stolen please sign the declaration below andLarge
Vehicles get theBus declaration
and Trailer witnessed and
stamped at your local Garda Station. Please note if you find or get your old learner permit back after applying for a
replacement, the old permit will no longer be valid.

I declare my learner permit lost/stolen. (circle as appropriate)

Signature of Applicant

I certify that the applicant has declared his/her learner permit lost/stolen.

Name of Garda

Signature of Garda

Part 3: Organ Donation (See Part 3 of accompanying guidance notes)

17. Place an X in the box provided if you would like code 115 to appear on your learner permit indicating
your wish to become an organ donor.

October 2016 Page 2

 Part 4: Driver Fitness (See Part 4 of accompanying guidance notes) Mandatory field
If you answer ‘Yes’ to any of the questions below 19 to 39 or 40(c), you will also be required to submit a medical report dated within one month of application date

18.* Do you need to wear glasses 28.* A serious problem with memory
or lenses for driving? Yes No or periods of confusion3 Yes No
(If yes Code 01 will be added to your licence) 29. * Persistent alcohol misuse
If in the past you answered ‘Yes’ to this question or dependency Yes No
and are now answering ‘No’ you must provide a 30. * Persistent drug misuse
current eyesight report with your application. or dependency Yes No
Health and Fitness 31. * Serious psychiatric illness or mental
health problems3 Yes No
Have you ever had, or do you currently suffer from,
any of the following conditions? 32. * Parkinson’s disease Yes No
19. * Diabetes treated by insulin or managed by tablets
which carry a risk of inducing hypoglycaemia eg. 33. * Sleep Apnoea syndrome Yes No
sulphonylureas. (Ask your doctor whether you are on
sulphonylureas or other medications which carry a risk 34. * Narcolepsy Yes No
of inducing hypoglycaemia.)  No need to tell us if 35. * Any condition affecting your
managed by diet alone or only by peripheral vision Yes No
medications which do not carry
a risk of inducing hypoglycaemia. Yes No
36. * Total loss of sight in one eye Yes No
20.*Epilepsy Yes No 37. * Any condition affecting both eyes,
21.*Stroke or TIAs with any associated
1 or the remaining eye if you only have
symptoms lasting longer one eye (not including colour blindness
than one month Yes No or short or long sight) Yes No
38. * A serious hearing deficiency which
22.* Fits or blackouts Yes No has worsened since your last
application/renewal Yes No
23.* Any type of brain surgery, brain abscess or severe
head injury involving in-patient treatment
or brain tumour or spinal injury 39. * Severe learning disability3 Yes No
or spinal tumour Yes No
40. * (a) Any persistent problems with
24.* An implanted cardiac pacemaker Yes No arms or legs which restricts your
driving to an automatic vehicle Yes No
25.* An implanted cardiac
defibrillator (ICD)2 Yes No 40. * (b) Any persistent problems with
arms or legs which restricts your
26.* Repeated attacks of sudden driving to an adapted vehicle Yes No
disabling dizziness Yes No
40. (c) If you have ticked yes to 40(a)
27. * Any other chronic neurological condition such or 40(b) has your condition deteriorated
as multiple sclerosis, motor neurone since your last application/renewal. Yes No
disease or huntington’s disease Yes No
1
A transient ischemic attack (TIA) is an event with stroke symptoms that lasts less than 24 hours before disappearing (sometimes called a mini-stroke).
While TIAs generally do not cause permanent brain damage,they are a serious warning sign of stroke.
2
An Implantable Cardioverter Defibrillator (ICD) is an electronic device which monitors your heart continuously. The ICD is programmed to detect abnormally
fast or slow heart rhythms.
3
If in doubt, please consult your family doctor.
A numeric code on your learner permit may indicate certain restrictions or conditions that affects your learner permit- including those related to a disability
or illness. Information about codes will be on the explanatory letter issued with your learner permit and on our website at www.ndls.ie. Where you need
an adaption to your vehicle on medical/disability grounds, or an existing adaption is being modified, you should contact the NDLS as a new code may be
needed on your learner permit.
Part 5: Declaration by Applicant (See Part 5 of accompanying guidance notes) *Mandatory field

41.* I hereby declare that:

Ireland is my normal place of residence. I am not currently disqualified (with the exception of a penalty point
disqualification or those referred to in question 13(b)) from holding a learner permit or driving licence in Ireland
or in the EU. The address given is my normal residence. The accompanying supporting documents relate to me.
The information I have given in this application is correct.
THIS DECLARATION MUST BE SIGNED AND DATED BY THE PERSON TO WHOM THE LEARNER PERMIT IS TO BE ISSUED

Applicant’s signature
(Please keep signature within the box)

Day Month Year
Information contained in this form may be subject to disclosure under Section 60 of the Finance Act, 1993 (No. 13 of 1993) as amended by Section 86 of the Finance Act, 1994 (No. 13 of 1994) and
regulations made thereunder. List of disclosees is registered with the Data Protection Commissioner. An electronic version of all information contained in this application may be retained for a period
of at least 20 years.Public Service Identity data collected on this form/provided by you may be used to maintain/authenticate your Public Service Identity, under Section 262(5) of the Social Welfare
Consolidation Act 2005 (as amended).  Only your Public Service Identity data may be shared with other public bodies under this provision.

Page 3
October 2016
Application Checklist for Learner Permit
You must apply in person at any NDLS centre. You may book an appointment at www.ndls.ie

For all applications for Learner permit you must supply;

• Application form for Learner permit D201 (Fully completed)

• Current/ most recent Learner permit
• If you do not have your most recent learner permit you must present
a completed lost licence declaration and photographic ID (question 16 on D201)
• NDLS medical form (dated within 1 month) if required (see page 3 of guidance notes)
• Evidence of CPC if required (see page 3 of guidance notes)
• Evidence of PPSN (list 3 on page 2 of guidance notes)
• If the address has changed since your last learner permit was issued,
you must provide evidence of new address (see list 2 on guidance notes, must be dated within 6 months)
• Photographic ID (list 1 on page 2 of guidance notes)
• Evidence of residency entitlement (seelist 4 on page 2 on guidance notes)
• Relevant fee (see page 1 of guidance notes)
• Your Photograph and signature will be captured at the NDLS office

The following additional information is required when applying for;

Option 1 – First time Learner permit Option 4 - Replace a lost or stolen Learner permit

• Theory test pass certificate (dated within 2 years) • A completed lost licence declaration
(see question 17 of application form)
• NDLS Eyesight Report form D502 (Fully completed)
(dated within 1 month) • Photographic ID.
(see list 1 on page 2 of guidance notes)
• Evidence of address dated within 6 months.
(Please see list 2 on page 2 of guidance notes.)
Option 5 - Personal Details Change
Option 2 - Renewal of a Learner permit
• Evidence of name change if name is changing
• If applying for a third or subsequent Learner permit (refer to www.ndls.ie or page 1 of guidance notes)
documentary evidence must be submitted that you • Evidence of new address (dated within 6 months)
have either sat a driving test (statement of driving if address is changing (seelist 2 on page 2 on guidance notes)
test outcome) or an acknowledgement of a • A completed NDLS medical form (dated within one month)
forthcoming test if your medical details have changed (see 3 of guidance notes)
Option 3 - Adding a Category to your Learner Permit Option 6 – Replace a damaged learner permit

• A theory test pass certificate if applicable • Photographic ID (see list 1 on page 2 on guidance notes)
(dated within 2 years)

• Damaged Driving licence
• Current Learner Permit
Option 7 - Already hold a full driving licence and are
• A completed NDLS medical form, if applicable.
applying for a Learner permit in a different category
(dated within 1 month)
• A theory test pass certificate
(if applicable) (dated within 2 years)

• Current Learner Permit

• Current Full licence

THE NDLS CENTRES ARE OPEN MONDAY TO FRIDAY 9.00AM – 5.00PM

(INCLUDING LUNCHTIME) AND SATURDAY FROM 9.00AM – 2.00PM.
VISIT WWW.NDLS.IE FOR THE MAP AND ADDRESS OF YOUR NEAREST
CENTRE OR DOWNLOAD OUR NDLS CENTRE APP: