THE UNION OF INDIA

MAHARASHTRA STATE MOTOR DRIVING LICENCE

DL No MH02 20040308800 DOI 12-03-2004
Valid Til 11-03-2024 (NT) 01-11-2019 (TR)
DLR 15-12-2016 FORM 7
RULE 16 (2)
AUTHORISATION TO DRIVE FOLLOWING CLASS
OF VEH#CLES THROUGHOUT INDIA
COV DO
MCWG 12-03-2004
LMV-TRR 12-03-2004
3W-TR 12-03-2004

DOB 20-02-1981 BG
Name SUNIL KUMAR TIWARI
SDW of. KISHAN BHAGWAN TIWARI
Add KAMALA BHAI KA TABELA SIDDHARTH NGSR
HIGHWAY BANDRA (E).MUMBAI

PIN 400051
Signatur & ID of
Sallys Signature/Thumb
impresSion of Hcic
sSUingAuthority: MH02 2016571
 FORM 1A M.BBS

practitioner at least
Registered medical
in by a
To befillead
1. Name of the applicant l
I T Y L e v c
2. SonWife/Da
Daughter of
CaOUDAV

( 20L
Fresent Address

4. Pemanent Address Blood Group-

5. Date of Birth 20nLlES LEducation

6. Identification Marks (1)-
(2)
(2)
wwwolle No. (1) addicted YesNo
evidence of being
he show any ?

S. (8) is The applicant to the best of yeur judgement Yes/No (h) Does tobacco of drugs
excessiveuse of alocohole,
YesNic
subject to epliepsy vertigo, or anymental aliment attacts of loss of
(1) Does he suffer from
likely to effect his driving efficitncy ? cause ?
consclousness from any
() Dose the applicant suffer from any herator Yes/No witeh each eye at a Yes No
G) Is he able to distinguish
udgemerit subjet to epliepsy, vartigo, or any a motor
mentai aliment likely to affect his driving efficiency ? distance of 35 meters in goods day light
car number plate ?
(c) is there any defect of Vision 7 if so, has it been Yos/No movement
any decent in
Yes No
comected by suitable spectacle. (k)ls he suffering from
am or limb?
(d) Can the applicant realdily distinguish the pig cntrol of muscular power of either
Yes/No what is the height oh the applicant ? Do you YesNo
mentary (0) our
(e) Does the applicant sufferfroma degree of defence consider that his haight will be dtsadvantage
Yes/No for him to have a clear vislon of the road while
which would prevent his hearing the ordinary
sound signais. driving ?
() Does the cant suffer from night blindness. Yes/No (m)ls he a mentally person Ili person? YesNo
(g) Has the applicant any deformity or loss of member (n) Does he suffer from any other diséâseor Yes No
Yes/No
which would interfere with the efficient disability ikely to cause his driving a motor
performance of his duties as a driver if so, give Vehicle a source of danger to the public
reasons in details.
(qii) Mental ability and Yes N
(o) Is he isyour opinion generally t as regards (iv) Hearing ability? Yes No

(bodifyhealth s/No (g) RH Factor of the applicant

(i) eye sight Yes/No
(p) Blood group of the applicant
Certify I havepersonally 8xamined the applicant
l also certify that while examing the applican I have direct specialattention to the distantvision and hearing abillity.
both extermities of thecandiddtp/and he ls medically not fit ifit
the candition of the arms. legs, hands and joints of
to hold à Drivina Licence.
Signature/DiMayur M. Waghela
M.B.B.S., M.S. (Ophthal
Name&Designation Gataract & Lasik Spacialist
DMayur M. Waghcla Medical Retina Specialis
Rege-Be-2010/04O8Z9
M.8.8.S., M.S. (Ophthah ofthe Medical Officer
Cataract &Lasik Spacialist
Medical Retina Speci alis Date
JRegd. Bo. 2010/04/0879
Signature of Candidate
of the Medical Officer is upon
manner part of his signature
Officer shall affix his signature over the photograph in a
Note (1) The Medical the Medical Office appointment is
Particulars of the Gazette where
the photograph and part on the certificate (2) serial number in this
of the Motor Vehicles Act. 1988 and the
with reference to subsection. (3) of section &
notity
list where his name appears.

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