D2-0>2020

i o 27ABITZ

See Je 52

AHIL
hame f tte arnicat
VALSALAR1AR
ctrers Name
46TH MAIN 2ND CROSS
a r e r t aatess
SR MVNAGAR RAMMAMURTHYNAGAR
Bargaiore KA
Bangaiore North
SB0015

TMC 2447
Temoorey ao BM NAGAR ROAD
Cfica dras fany EDPALL
S2t24

28-4-1995

25 years
c e r cae acicano Hole i n Neck

ertficzicr a s

Deeratic

of
a D
rirm
y uMrfroepliesy. irom
suco0en ataks Yes (y
any tas
cs irsioses r podiress
orfyou heve
(

eye
re y 20e1o disirgus wm e r period of
e c a r g icence to
drve a venidie for a
C
f
tan fve year and you
tave is. ne sighi of one
erod f fve and
f
he appication
s y i No
eye ter t e a d
wheel
wt ar outode marror on me sHeing
ce i
E s zzdancz 5mereS ingood
iCe W
ayigt ( w g a s E wom) a meON Ztnumberpate

Cmareo ice anc is y ae you ufering Yes

frorn ey Hetin rOETe r mysular pOwer f ether

Yes 1
DyouAer trarn rigrt lindress
be unaie to her and f the
e Are yo e i as t Yes /
acplicasn is for oriving a ligrt motor venicie wih or without

Yes/ N
r d vability kely to
) Do you uMer trom any ther diseee
casse yo driving of a mor vehe
to te a soure of danger

decdaration
inerefyy eriare ha, the best f ny krowedye and belief, the particulars given above and the

g atuse or thymb mpression of the applicant

(AKHIL

e alicart na answers Yes' to any odthe quUestions (a).fc)e), ") and (9) or "No' to ether
A te tsentsns (o) and (d) shoud ampify his answers with full particulars, and may be
4irer Gve turner informatin relating thereto