FORM 2

[See rules 10, 14, 17 and 18]

Appl No:2655798125 Dt:05-07-2025

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

L.A. BANKURA

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 (LMV NTV)

Adapted Vehicle (vehicles for use by Divyang)

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.
 Appl No:2655798125 Dt:05-07-2025
2. Personal details of the Applicant (in Capital Letters)

Details of Aadhar card, if already available with the Aadhar Card number
applicant.
Not Furnished

Aadhar Card application number

Details of Aadhar application number if applied.

First Name Middle Name Last Name

LAKHSMAN BAURI

Son/ wife/ daughter of : BALARAM BAURI

Identification mark :

Gender Date of Birth:

Male Female Transgender
(Tick √)
20-12-1983
(dd/mm/yyyy)

Educational Blood Group

Qualification Not Specified / NA O+

Email Mobile number

(optional) XXXXXX4470

Landline Number (optional)

3. Name of(Tick √) Father Mother Husband Guardian

First Name Middle Name Last Name

BALARAM BAURI

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 No P S GANGAJALGHATI P S GANGAJALGHATI

Street/Locality/Police Station

VILL DUBERDANGA DIST

Location/Landmark VILL DUBERDANGA DIST BANKURA BANKURA

Village/Town Duberdanga

SubDist/Taluk/Mandal Gangajalghati Gangajalghati

District Bankura Bankura

State West Bengal West Bengal

Pin code 722142 722142

 Appl No:2655798125 Dt:05-07-2025
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

Training period in the Driving School From date To date

6. Particulars of existing Licence (Learner’s or Permanent)

Licence Number WB39 20040070686

LMVCAB, LMV, LMV-TR, TRANS
Class of Vehicle(s)

Name of the Licencing Authority which issued L.A. DURGAPUR

the Licence

Validity Period From date 27-02-2004 To date 17-04-2031

Valid To:TR->06-07-2025,NT->17-04-2031,

7. List of Documents attached (Please refer to the attached annexure and tick)

Self-Declaration as to Physical Fitness

(a) Do you suffer from epilepsy, or from sudden attacks of loss of consciousness or giddiness from any cause ? 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 Yes
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 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 from any defect in movement, control or muscular power of either No
arm or leg ?
No
(d) Do you suffer from night blindness ?

(e) Are you so deaf as to be unable to hear ( and if the application is for driving a light motor vehicle, with or without No
hearing aid) the ordinary sound signal ?

(f) Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be a source of danger No
to the public, if so, give details?
DECLARATION
I am willing to donate my organ/tissue in case of death No
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: 05-07-2025 Signature of the Applicant

DECLARATION under sub-section (2) of section 7 of the Motor Vehicles Act, 1988
Not Applicable
Shri/Smt./Kumari_______________________________________________________son/daughter of Not Applicable

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 for his /her

I shall inform the licensing authority in writing for the cancellation of the licence.I give my consent for his / her obtaining the learner’s licence.

Name of the parent / guardian: Not Applicable

Relationship with the applicant: Not Applicable
Signature of the parent / guardian
 FOR OFFICE USE ONLY

Appl No:2655798125 Dt:05-07-2025

1. The applicant LAKHSMAN BAURI is exempted from production of a medical certificate under
Rule 6 of the Central Motor Vehicles Rules, 1989;
YES/NO

Learner’s licence may be issued.

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

Learner’s licence may be issued.

3. Preliminary Test to check adequate knowledge and

understanding of the matters namely traffic sighs, traffic Date of Test Result ( ) Testing Authority
signals, duties of driver in case of his vehicle being
involved in an accident, or documents to be carried
while driving etc,. Subrule (1) of Rule 11 of the Central
Motor Vehicles Rules, 1989 Pass / Fail / Absent/
Exempted
(Name:LAKHSMAN BAURI)

Driving Test (Rule 15 of the Central Motor Vehicles Rules, Date of Test
1989) Result Pass / Fail

The Learner’s licence / Driving Licence is Issued Refused

Signature of licensing authority (or other person

authorised in this behalf)
 ANNEXURE Appl No:2655798125 Dt:05-07-2025

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

Other documents to be enclosed or uploaded if applicable

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