Form L. L. D.

Intimation of loss or destruction of driving licence and

application for duplicate
(See Rule 25)
To
The Licensing Authority,
.....................................

1............................................................ of (Permanent Address).....................................................................

...........................................................................................................................................................................
and(present address)........................................................................................................................................
(Fathers Name) .............................................. hereby report that driving Licence No ....................................
issued by Licensing Authority .................................................................................................. on or about the
day of .................................... in No .................................. and on ............................................. for the period
up to .................................................. has been lost / destroyed (i) in the following circumstances:
2.

I furnish below further details of the licence a) Class of vehicles for which the licence is valid
........................................................................................................................................................
b) The number and date of the Authorisation and the Licensing Authority which issued the
authorisation to drive as apaid employee (if so authorised)
......................................................................................................................................................
c) Whether authorised to drive transport vehicles if so, the date and authority
.....................................................................................................................................................
d) Serial number of Badge, if any, issued and by whom issued?
.....................................................................................................................................................
e) Endorsement of punishments
.....................................................................................................................................................

3.

I hereby apply for a duplicate licence and tender Rupees...........................................................

4.

I attach two clean copies of a recent photograph of myself (i)

5.

I hereby declare that the above particulars are to the best of my knowledge correct.

Date :

..................................
Signature of applicant

Note : (i) Strike out alternative not required and items not applicable. If the column is not sufficient,
particulars to be furnished on a separate sheet to be appended.