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Acknowledgement of Online Application For Services On Existing DL

This document is an acknowledgement of an online application submitted for replacement of a driving license on an existing license. It provides details of the applicant such as name, father's name, driving license number, and address. It also contains a CMV Form 1 which includes a declaration of physical fitness filled out by the applicant stating they do not suffer from conditions like epilepsy or blindness that would impair their ability to drive.

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Dhiraj Kumar.
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31 views2 pages

Acknowledgement of Online Application For Services On Existing DL

This document is an acknowledgement of an online application submitted for replacement of a driving license on an existing license. It provides details of the applicant such as name, father's name, driving license number, and address. It also contains a CMV Form 1 which includes a declaration of physical fitness filled out by the applicant stating they do not suffer from conditions like epilepsy or blindness that would impair their ability to drive.

Uploaded by

Dhiraj Kumar.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Acknowledgement of Online Application for Services on Existing DL

*** This Acknowledgement is generated in response to the Application submitted Online at


https://parivahan.gov.in/sarathiservice/ for availing Services as detailed.

I. Applicant / Licence Details :

1. Application Number : 2595558119 Dt:26-08-2019

2. RTO Office where Service : DTO, ROHTAS

3. Driving Licence Number : BR24 20160069596

4. DL Issued by (OLA Office Name/Code) : DTO, ROHTAS

5. DL Issue Date : 30-09-2016

6. Valid Upto : NT : 29-09-2036 Transport :

7. Name of the Licencee : DHIRAJ KUMAR

8. Father's Name : CHHOTE LAL PRASAD

II. Requested Services :

SlNo Services Name


1 REPLACEMENT OF DL

Signature of the Applicant

( DHIRAJ KUMAR )
CMV FORM 1 Appl No: 2595558119 Dt:26-08-2019
[See rule 5(2)]
Application –cum-declaration as to the physical fitness

1.Name of the applicant : DHIRAJ KUMAR

2. Father's Name : CHHOTE LAL PRASAD

3.Permanent address : AT-SICHAI COLONY NEAR D.I.G.OFFICE,


DEHRI ON SONE,
DEHRI,ROHTAS
821307

4.Temporary address : AT-SICHAI COLONY NEAR D.I.G.OFFICE,


Official address (if any) DEHRI ON SONE,
DEHRI,ROHTAS
821307

5. (a) Date of birth : 12-01-1998


(b) Age on date of application : 21 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


( DHIRAJ KUMAR )

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.

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