Smart Card License Document

Acknowledgement of Online Application for Services on Existing DL *** This Acknowledgement is generated in response to the Application submitted Online at https://parivahan.gov.in/sarathiservice/

for availing Services as detailed. :

I. Applicant / Licence Details 1. Application Number

:

2277758121 Dt:17-07-2021

2. RTO Office where Service

:

L.A. KASBA

3. Driving Licence Number

:

WB01 20161060631

4. DL Issued by (OLA Office Name/Code)

:

P.V.D. KOLKATA

5. DL Issue Date

:

16-02-2016

6. Valid Upto

:

NT : 04-02-2026 Transport :

7. Name of the Licencee

:

DIPADDUTI CHATTERJEE

8. Father's Name

:

NIL RATAN CHATTERJEE

II. Requested Services

:

SlNo Services Name 1

REPLACEMENT OF DL

Signature of the Applicant ( DIPADDUTI CHATTERJEE )

Appl No:2277758121 Dt:17-07-2021

CMV FORM 1 [See rule 5(2)] Application –cum-declaration as to the physical fitness

1.Name of the applicant

:

DIPADDUTI CHATTERJEE

2. Father's Name

:

NIL RATAN CHATTERJEE

3.Permanent address

:

1077, G-I BLOCK SAROJINI NAGAR, N DMC DILSHAD GARDEN,EAST DELHI 110023

4.Temporary address Official address (if any)

:

28/43//A RANGANATHPUR COLONY THAKURPUKUR ROAD KOLKATA (M CORP.),KOLKATA 700063

5. (a) Date of birth

:

11-08-1965

:

55 years

(b) Age on date of application 6. Identification marks

:

Declaration : (a) Do you suffer from epilepsy, or from sudden attacks of loss of consciousness or giddiness from any cause ? (b) Are you able to distinguish with each eye ( or if you have held a driving licence to drive a motor vehicle for a period of not less than five years and if you have lost, the sight of one eye after the said period of five years and if the application is for driving a light motor vehicle other than a transport vehicle fitted with an outside mirror on the steering wheel side) or with one eye, at a distance of 25 metres in good day light (with glasses , if worn) a motor car number plate?

Yes/No

Yes/No

(c) Have you lost either hand or foot or are you suffering from any defect in movement, control or muscular power of either arm or leg ?

Yes/No

(d) Do you suffer from night blindness ?

Yes/No

(e) Are you so deaf as to be unable to hear ( and if the application is for driving a light motor vehicle, with or without hearing aid) the ordinary sound signal ?

Yes/No

(f) Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be a source of danger to the public, if so, give details?

Yes/No

I hereby declare that, to the best of my knowledge and belief, the particulars given above and the declaration made therein are true.

Signature or thumb impression of the applicant ( DIPADDUTI CHATTERJEE ) Note : - (1) An applicant who answers 'Yes' to any of the questions (a),(c),(d), (e) and (f) or 'No' to either of the questions (b) should amplify his answers with full particulars, and may be required to give further information relating thereto. (2) This declaration is to be submitted invariably with Medical Certificate in Form 1-A.

Transport Department Government of West Bengal e-Receipt For Online Driving License Office Name

L.A. KASBA

Receipt Date

17-07-2021

Applicant Name

DIPADDUTI CHATTERJEE

Receipt No

WBU/266517

Date of Birth

11-08-1965

Bank / Gateway

GRIPS

License No

WB01 20161060631|DL

Bank Reference No

192021220032524518

Application No

2277758121

Transaction ID

WB2021U22224615

Application Date

17-07-2021

Transaction Name

Fee Amount

Additional Fee / Fine

DLREPLACE

200.00

0.00

200.00

Service Fee

20.00

0.00

20.00

Transaction Fee

20.00

0.00

20.00

Class of Vehicles

Total Amount Total Amount (In Words)

Two Hundred and Forty Rupees only

Note: Visit the Concerned Office with Required Forms and Documents along with this Receipt

SOWRCP001

Total

240.00