8/11/2019 Driversl Appl

1/2

GUYANA REVENUE AUTHORITY

A p p l i c a t io n

R en ew a l fo r D ri v er s , P r o v is io n a l C o n d u c t o r s L i c e n c e

La st N am e First N am e

M id dle In t.

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Address

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Sex

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C olour of eyes

ID T yp e

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N atio nal Identi f ication

1 0 N u m be r

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Passpor t

oO th er, p le ase specify .

T IN

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0N ew Licen ce

l u \

Re n e wa l

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D r iv e r L ic e nc e

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provisiona l L icen ce oC o nd uc to r L ic en ce

o C ar 0an 0C ycle 0M in i B us 0H ire C ar

o M otor B us

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Tractor

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Lorry

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w hich test w as m ade

R e su lt o fT e st ,

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T he A ppl icant is required to furn ish answ ers to t~e fo llow ing questions by se l~ cting Y es or N o 'O p po sit e e ac h q ue st io n. Yes

1 . D o y o u s uffe r from E p ile p sy , s u dd e n a tt ac k s 9 f d is a bi lit Y, g id d in e ss o r f ain tin g ? 0

2 . A re y ou ab le to re ad fro m a d istance pf 2 5 y ds in g oo d d ay lig ht (w ith g la ss es , if w orn ) a M oto r Veh ic le 0

n um b er p la te c on ta in in g s ix ( 6) le tte rs a nd figures? ,

3 . H ave y ou lost e ith e r h an d o r fo ot, o r a re y ou s ufferin g fro m a ny de fe ct in m o ve m en~ control, '

0

or m uscular p ow e r o f e ith er a rm o r le g?

if y es , g ive par ticu la rs .

N o

o

o

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de cla re that Iam no t s u ff er in g from any.o th er d is ea se o r d is ab ility , w h ic h w o uld b e lik ely to c au se th e d riv ing by m e o f a m oto r v eh ic le to be

a s cu rc e o f d an ge r to tt ie public. . ,' . :

Ifurther dec l ar e t haI to th e b es t o f m y in fo rm atio n a nd p artic u la rs g iv en i n t he d e cl ar at io n s o n t hi s a p pl ic a ti on he reof are t rue. .

I

fur ther declare th at it is a n o ffe n'c e fo r a p ers on to u se a m oto r v eh ic le o n p ub lic ro ad u nle ss th ere is in fo re a p llic y o n th e i ns ur ance or

.a s ~ cu rity agains t th ird p a rt y r is ks c o ve ri ng. th e u se b y t hat pe rs o n o f t ha t v e hi cl e.

S i nature

Date

Appiic arit 'w ho answer~ y es t o q u es ti on 3 i n d e cl ar at io n o f P h ys ic a l f it ne s s 'm ay eit he r ( 1).c la im to b e s u bje cte d to a driv ing test,

(1 1) si~, the E Dec la r ~t ion , ov e rl eaf , i f i n t he pos ition to do so. .

I [J :J [J :J

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M otorV ehic les & R oad T raffic R egulat io ns

8/11/2019 Driversl Appl

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GUY N R V NU UTHORI TY

A p p l i c a t i o n

R en ew a l f o r D ri v er s , P r o v is io n a l

C o n d u c t o r s L i c e n c e

a im to b e s ub jec t t o a tes t t o m y f i t n es s o r a b il i t y t o d ri v e a m o to r v eh ic le o f t h e c la s s o r c las ses s pec if i ed in t h is ap p l i c at io n .

1 / I

i n at u re

-

Da t e

1 - = c : r : J = - o

= [ J : J = I V I

= C l I I J = y = - y

. I h er eb y d ec la re t ha t a d ri ve rs ' c er tif ic ate u nd er t he M o to r V eh ic le s' o rd in an ce , 9 5 D riv ers ' L ic en ce u nd er th e M oto r V eh ic le a nd R oa d T ra ffic

O rd inance, w a s issued to m e on the -- -- --by the

c ertify in g a uth ority to d riv e a m oto r ve hicle o f th e typ e

in respec t o f w hich a drivers ' licence is n ow app lied for b y m e a nd the date m y las t ap plica tio n fo r a drivers ' c er tif ic ate th e d is ea se o r p hy sic al

d is ab ilit y from w hich I a m suffering has not becom e m ore acute a nd that I a m not su ffering from a ny d ise a se o r d is ab ility 1 9t d is clo se d o n s uc h

l as t a p plication.

Da t e

C la ss o f L ic en c e

E xp ir at io n D at e

1

/

L ic en ce C ov er N um b er

1 --- -

L ic en ce N um b er

C er ti f i c at e o f C om p eten c e N um b er

D at e Is s ue d

F o r e ig n L ic en c e N um b e r C o u n t r y

1 - - - - 1 1 _

1 c : r : J [ J : J ~ 1 /

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E xp ir at io n D at e ,

1 c : r : J [ J : J [IIIJI

M o to r V eh ic le s

R o ad T ra ff ic R eg u la ti on s .