REPUBLIC OF THE PHILIPPINES DEPARTMENT OF TRANSPORTATION & COMMUNICATIONS LAND TRANSPORTATION OFFICE

East Avenue, Quezon City FIELD OFFICE

LT O F O RM NO . 21

No.
3 SUBM I T T HI S F O RM TO TH E

1 AC CO M PLI SH TH E F O RM CO RREC TL Y

INSTRUCTIONS
2 PR IN T DAT A LEG IBL Y I N CAPI T AL LET TER S NAM E ( Fa m il y Na m e , Fir st Na m e , Mi d d le Na m e )

CSR /EVA LUAT O R TO G ETH ER WI T H T HE REQ UI RED SUP POR TI NG DO CU M ENT S

APPLICATION FOR DRIVER'S LICENSE

P RES E NT ADDRE SS

(No . , S t re e t , Ci t y/ M u n ic ip a l it y , Pr ov in c e )

TE L NO. / CP NO. T IN

NATI O NALI TY GE NDE R

(F/ M )

BI RTH DAT E

(M M / DD/ YY )

H EIG HT ( cm ) W EI GH T( kg )

TO BE ACCOMPLISHED BY LTO PERSONNEL ONLY TO BE ACCOMPLISHED BY LTO PERSONNEL ONLY LICENSE TO BE ACCOMPLISHED BY LTO PERSONNEL ONLY NUMBER

TYPE OF APPLICATION (TOA)

A. A. N EW D F OR EIG N LI C. CO NVERSI O N B. B. D ELI NQ UENT / DO RM ANT E REN EWAL CHAN GE CI VI L STAT US 1 CHAN GE NAM E CHAN GE DAT E OF BIR TH 2

RESTRICTION CODE
MOTORCYCLE/MOTORIZED TRICYCLES / E- BIKES (LSV) TRIKES (A-1) VEHICLES UP TO 4500 KGS. GVW (MANUAL AND AUTOMATIC CLUTCH) VEHICLES ABOVE 4500 KGS. GVW (MANUAL AND AUTOMATIC CLUTCH) (MANUAL AND AUTOMATIC CLUTCH) AUTOMATIC CLUTCH ONLY UP TO 4500 KGS. GVW AUTOMATIC CLUTCH ONLY ABOVE 4500 KGS. GVW ARTICULATED 1600 GVW AND BELOW ARTICULATED 1601 UP TO 4500 GVW ARTICULATED 4501 GVW AND ABOVE (TRUCK - TRAILER)

L IC ENSE F ADD IT I ON AL REST RI CT IO N CO DE C. C HANG E CLASSI F IC ATI O N G DU PLI CAT E

OT HER S

PRO F T O NO N- PR OF H REVI SI ON O F R ECO RDS 3 NO N- PRO F T O PR OF CHAN GE ADD RESS NO N- PRO F T O PR OF CHAN GE ADD RESS TYP E O F LIC EN SE A PPL IED D RI VIN G S KI LL A C QU I RE D OR D SA ) ( T L A) EDU CAT I ON AL A TT AI NM EN T ( (EA)
FO R W ILL BE A CQ U IR ED TH R U

1 STU DENT PERM I T 1 DRI VI NG SC HO OL 1 I NF OR M AL 4 VO CAT IO NAL 5 2 NO N- PRO F ESSIO NAL SCH OO LI NG 5 CO LL EGE 6 3 PRO FESSI O NAL 2 LI CENSED PR IVAT E 2 ELEM EN TAR Y 6 PO ST G RADU ATE 7 4 CO NDU CT OR PERSO N 3 HI G H SCHO O L 8 BL O OD TY P E ORGA N DONO R YE S NO CI VI L S TATUS (CS ) EY E S C OM PL EX HAI I ON R 1 . S I NGL E 1 . BLACK 1. BL ACK 1. LI G HT 1. LI G HT 2 . M A RRI ED 2 . BRO WN 2. BRO W N 2. M EDI UM 2. F AIR 3 . W I DOW / ER 3 . BLO NDE 3. G RAY 3. HEAVY 3. DAR K 4 . S E PA RA TED 4 . GR AY 4. O TH ERS 5 . OT HER S ( Sp ecif y) ( Speci fy ) BUI L T

CONDITIONS
A WEARING CORRECTIVE LENSES. B DRIVE ONLY WITH CUSTOMIZED VEHICLE C DRIVE ONLY W/ SPECIAL EQUIPMENT FOR UPPER
OR LOWER LIMBS

BI RTHP LACE

(Ci t y/ M u ni c ip a li t y, P ro vi n ce )

FAT HER' S N AME

(Fa m i ly Nam e , Fi rs t N am e , M id d l e Na m e ) i n di ca t e e ve n i f de c e as e d

D DAYLIGHT DRIVING ONLY E WITH HEARING AID

M OT HER' S NAM E

(F am i ly Na me , Fi rs t Na me , M id d l e Nam e ) i n d ic at e e v en i f d ec e a se d

COMPUTATION OF FEES APPLICATION FEE P

AMOUNT

S PO USE NAM E

(Fa m il y Na m e , Fi rst Na m e , Mi d d le Na m e ) in d i ca t e e ve n if d e ce a s e d

COMPUTER FEE TOTAL P

E MP LO YE R' S BUS I NE SS NAM E T EL N O.

LICENSE FEE ADDITIONAL RESTRICTION CODE CHANGE CLASSIFICATION REVISION OF RECORDS COMPUTER FEE COMPUTER FEE OTHERS (SPECIFY)

E MP LO YE R' S BUS I NE SS ADDRE SS

F IL L TH IS UP O NLY I F YO UR NAM E ABOVE I S D IF F ERENT F RO M YO UR N AM E I N PREVI OU S L IC ENSE

P REV I OUS NAM E

( Fa m il y Na m e , Fir st Na m e , M i d d le Na m e)

P TOTAL P

TH IS I S T O C ERT IF Y TH AT I HAVE CA REF UL LY EVAL UA TED T HI S APPL IC AT IO N I NCL UD IN G T HE SUPPO RT IN G DO CU M ENT S THI S I S T O CE RTI FY THA T T HE I NF ORM AT I ON I HAV E G IV E N I S TR UE A ND CORRE CT. S IG NA TURE O F A PP L I CANT P RI NT NAM E / SI G NAT URE

QR-OPD-ADL R-1 03/01/10