FORM Appl No.

553080817 Dt:15-07-2017
[See rule 18(1)]
FORM OF APPLICATION FOR THE RENEWAL OF DRIVING

I, Shri :: JAMES CHRISTU RAJ CHANDR U

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

Father's Name :: JAMES A

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

hereby apply for the renewal of my driving licence which is attached and particulars of which are as

a) Driving Licence Number :: TN02 20080000679

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

b) Date of issue :: 18-01-2008

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

c) Licensing Authority by which the licence :: RTO, POONAMALEE,

................................................
issued

d) Licensing Authority by which the licence :: RTO,CHENNAI (NORTH WEST),

was last renewed, number and date of .................................................
renewal TN02 20080000679 Dt: 18-01-2008
.................................................

e) Class of vehicles authorised to be driven :: MCWG , LMV

f) Date of expiry of licence to drive ::

(i) transport vehicle :: ................................................

(ii) vehicles other than transport :: 09-04-2016

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

My present address is :: PLOT 629 LIG II TNHB

AVADI
CHENNAI,
600054

If this address is not entered on the :: PLOT 629 LIG II TNHB

licence I do/do not wish that it should be AVADI
so entered. CHENNAI
600054

If the licence is not attached, reasons :: ................................................

why it is not available?
If the licence was not renewed within thirty :: ................................................
days of the days of the date of expiry,
reaons for delay

The renewal of licence has not been :: ................................................

refused by any Licensing Authority.

I have not been disqualified for holding or :: ................................................

obtaining a driving licence. My licence has
not been revoked.

I enclose three copies of my recent :: ................................................

passport size photographs.

I have paid the fee of Rs. :: ................................................

Challan No. / Receipt No. :: ................................................

I hereby declare that to the best of my knowledge and belief the particulars given above are true.

Date: 15-07-2017 Signature or thumb impression of the

JAMES CHRISTU RAJ CHANDR U
Name ………………………………….

Address PLOT 629 LIG II TNHB

AVADI
CHENNAI,
600054
 CMV Form 1-A Appl No: 553080817 Dt:15-07-2017
[See rules 5(1),(3),7,10(a),14(d), and 18(d)]
Medical

[ To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person
authorised in this behalf by the State Government referred to under sub-section (3) of Section 8]

1.Name of the applicant : JAMES CHRISTU RAJ CHANDR U

2. Identification marks :

3. (a) Does the applicant, to the best of your judgment, suffer from any defect
of vision? If so, has it been corrected by suitable spectacles ? Yes / No

(b) Can the applicant, to the best of your judgment, readily distinguish the
pigmentary colours, red and green ? Yes / No

(c) In your opinion, is he able to distinguish with his eye sight at a distance
of 25 metres in good day light a motor car number plate ? Yes / No

(d) In your opinion, does the applicant suffer from a degree of deafness
which would prevent his hearing the ordinary sound signals ? Yes / No

(e) In your opinion, does the applicant suffer from night blindness ? Yes / No

(f) Has the applicant any defect or deformity or loss of member which would
interfere with the efficient performance of his duties as a driver? If so, give Yes / No
your reasons in details.

(g) Optional
(a) Blood group of the applicant (if the applicant so desires that the ..........................
information may be noted in his driving licence).

(b) RH factor of the applicant (if the applicant so desires that the ..........................
information may be noted in his driving licence).
Declaration made by the applicant in Form 1 as to his physical fitness is attached

Certificate of Medical Fitness

I certify that : -

(i) I have personally examined the Shri : JAMES CHRISTU RAJ CHANDR U

(ii) that while examining the applicant I have directed special

attention to his / her distant vision;
(iii) while examining the applicant, I have directed special
attention to his / her hearing ability, the conditions of the arms,
legs, hands and joints of both extremities of the applicant; and
(iv) I have personally examined the applicant for reaction time,
side vision and glare recovery (applicable in case of persons
applying for a licence to drive goods carriage carrying goods of
dangerous or hazardous nature to human life.)

_____________________________________________________________________.

The applicant is not medically fit to hold a licence for the following reasons : -

______________________________________________________________________.

Signature :

1. Name and designation of the of Medical Officer

/ Practitioner

(Seal)
2. Registration Number of Medical Officer

Signature or thumb impression of the candidate

( JAMES CHRISTU RAJ CHANDR U )

Date :

Note : -
1. The medical Officer shall affix his signature over the photograph affixed in
such a manner that part of his signature is upon the photograph and part
on the certificate.
2. Dumb persons without deafness may be granted a valid certificate
of driving licence for non-transport vehicle.
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