FORM L. L. D.

[See Rule 12(1)]

Intimation of loss of destructive of driving licence and application for duplicate.

To,

The Licensing Authority _________________________________________________________

I, ___________________________________________________________________________
of (Permanent address) _________________________________________________________
of (Present address) ___________________________________________________________
(Father’s/Husband’s name) ______________________________________________________
hereby report that driving licence No._________________________________________ issued
by the Licensing Authority _____________________________________________________ of
or about the ______________________________ day of _________________________20
has been Lost/Destroyed Ο in the following circumstances

2. I here by apply for a duplicate driving licence and tender five rupees by cash/money
order cheque/challan.

3. I attach two clear copies of recent photograph of myself Ο

4. I further declare that my driving licence is not impounded by any authority.

5. I hereby declare that there have been following / No. Ο endorsement by the Court since
the date of last renewal / grant Ο

Date of endorsement Court Offence Punishment

Dated ___________ 20 _____

Si
Signature or thumb impression of appilcant

(Duplicate signature or thumb impression)

(Duplicate signature or thumb impression)

For use in the office of the Licensing Authority

( PART – I )

Ο Duplicate of driving lincence No. ________________ ) first granted on __________________

has been issued by me this ____________ day of ___________ 20

Ο Application refused in letter No. ___________ dated the _________ to the applicant giving
reasons.

Dated ________________ 20 Licensing Authority ___________________

(Ο Strike out alternative not required.)

Government Printing Press, Daman – 09/2003 – 5000.