Application For Replacement Of Driving License.pdf

Application for Replacement of Driving License

Application Number:
Date of Application:
Name of Block & Tehsil:

Fields marked with asterisk () are mandatory.

Part-1 Personal Details

Details of Person Filling the Application Form

Self-Attested Photo of Beneficiary

1. Name:
2. Address:
3. Relation with Beneficiary:

Personal Data of Beneficiary

4. Name:
5. Gender:
Male/ Female/ Transgender
6. Date of birth:
7. Age (if Date of birth not known):
8. Place of Birth:
9. Father's Name:
10. Mother's Name:
11. Region:
Urban/ Rural
12. Permanent Address:
PIN Code:
Sub District/ Tehsil:
District:
State:
Village (In case of Rural area):

Correspondence address same as permanent address

13. Region:
Urban/ Rural
14. Correspondence Address:
PIN Code:
Sub District/ Tehsil:
District:
State:
Village (In case of Rural area):

15. Marital Status:
Married/ Unmarried/ Divorced/ Separated/ Widowed
16. Spouse Name:
(Only in case of married/ separated and widowed)
17. Email ID:
18. Contact Phone Number: *
19. Voter ID Card Number:
20. Aadhaar Number (UID):
21. Aadhaar Enrollment Number (if Aadhaar not issued):

Declaration

I, hereby declare that I will maintain the secrecy of the application and the registration process. I also declare that I will not disclose any information related to the application and the registration process to anyone.

I also declare that I will not use the information provided in the application for any purpose other than the purpose of the application.

I also declare that I will not make any changes to the application or the registration process without the permission of the authority.

I also declare that I will not use any fake or forged documents to obtain the driving license.

I also declare that I will not make any false statements or representations to obtain the driving license.

I also declare that I will not use any unfair means to obtain the driving license.

I also declare that I will not make any changes to the application or the registration process after it has been submitted.

I also declare that I will not use any fake or forged documents to obtain the driving license.

I also declare that I will not make any false statements or representations to obtain the driving license.

I also declare that I will not use any unfair means to obtain the driving license.

I also declare that I will not make any changes to the application or the registration process after it has been submitted.

Signature of the Applicant