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.
