Form L. L. D.

Intimation of loss or destruction of driving licence and

application for duplicate
(See Rule 25)

To
The Licensing Authority,

.....................................

1............................................................ of (Permanent Address).....................................................................

...........................................................................................................................................................................

and(present address)........................................................................................................................................

(Father’s Name) .............................................. hereby report that driving Licence No ....................................

issued by Licensing Authority .................................................................................................. on or about the

day of .................................... in No .................................. and on ............................................. for the period

up to .................................................. has been lost / destroyed (i) in the following circumstances:

2. I furnish below further details of the licence -

a) Class of vehicles for which the licence is valid

........................................................................................................................................................
b) The number and date of the Authorisation and the Licensing Authority which issued the
authorisation to drive as apaid employee (if so authorised)

......................................................................................................................................................
c) Whether authorised to drive transport vehicles if so, the date and authority

.....................................................................................................................................................
d) Serial number of Badge, if any, issued and by whom issued?

.....................................................................................................................................................
e) Endorsement of punishments

.....................................................................................................................................................

3. I hereby apply for a duplicate licence and tender Rupees...........................................................

4. I attach two clean copies of a recent photograph of myself (i)

5. I hereby declare that the above particulars are to the best of my knowledge correct.

..................................
Date : Signature of applicant

Note : (i) Strike out alternative not required and items not applicable. If the column is not sufficient,
particulars to be furnished on a separate sheet to be appended.