REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF TRANSPORTATION & COMMUNICATIONS

LAND TRANSPORTATION OFFICE

LTO FORM NO. 21

East Avenue, Quezon City

No.

FIELD OFFICE

1 ACCOMPLISH THE FORM CORRECTLY

INSTRUCTIONS
2 PRINT DATA LEGIBLY IN CAPITAL LETTERS

3 SUBMIT THIS FORM TO THE

CSR/EVALUATOR TOGETHER WITH
THE REQUIRED SUPPORTING
DOCUMENTS

APPLICATION FOR
DRIVER'S LICENSE

NAME (Family Name, First Name, Middle Name)

H E

R N A N D E Z

E S O U

S H A L O M

PRESENT ADDRESS (No., Street, City/Municipality, Province)

H E R N A N D E

TEL NO. / CP NO.

B4, L20, ST. PETER STREET, ST. FRANCIS HOMES 8, BRGY. POOC,
STA. ROSA CITY, LAGUNA

TIN

N/A

(0917) 723 2702

TO BE ACCOMPLISHED BY LTO PERSONNEL ONLY

NATIONALITY

GENDER (F/M)

HEIGHT(cm) WEIGHT(kg)

BIRTH DATE (MM/DD/YY)

FILIPINO

160 cm 52 kg

01/11/99

LICENSE
NUMBER

RESTRICTION CODE

TYPE OF APPLICATION (TOA)

A.
x A. NEW

D. FOREIGN LIC. CONVERSION

CHANGE CIVIL STATUS

B. B. DELINQUENT/DORMANT

E RENEWAL

CHANGE NAME

CHANGE DATE OF BIRTH

LICENSE
C. CHANGE CLASSIFICATION

ADDITIONAL RESTRICTION CODE

G DUPLICATE

PROF TO NON-PROF

DRIVING SKILL ACQUIRED OR

WILL BE ACQUIRED THRU

1 STUDENT PERMIT

(DSA)

1 DRIVING SCHOOL

(MANUAL AND AUTOMATIC CLUTCH)

SCHOOLING

3 PROFESSIONAL

2 LICENSED PRIVATE

4 CONDUCTOR

2 ELEMENTARY

PERSON

AUTOMATIC CLUTCH ONLY UP TO 4500 KGS. GVW

4 VOCATIONAL

AUTOMATIC CLUTCH ONLY ABOVE 4500 KGS. GVW

5 COLLEGE

ARTICULATED 1600 GVW AND BELOW

6 POST GRADUATE

ARTICULATED 1601 UP TO 4500 GVW

ARTICULATED 4501 GVW AND ABOVE (TRUCK - TRAILER)

3 HIGH SCHOOL

YES

ORGAN DONOR

BLOOD TYPE

VEHICLES ABOVE 4500 KGS. GVW

EDUCATIONAL ATTAINMENT (EA)

1 INFORMAL

2 NON-PROFESSIONAL

VEHICLES UP TO 4500 KGS. GVW

(MANUAL AND AUTOMATIC CLUTCH)

CHANGE ADDRESS

TYPE OF LICENSE APPLIED

(TLA)
FOR

MOTORCYCLE/MOTORIZED TRICYCLES /
E- BIKES (LSV) TRIKES (A-1)

OTHERS

H REVISION OF RECORDS

NON-PROF TO PROF

NO
CIVIL STATUS (CS)

x 1.SINGLE
2.MARRIED
3.WIDOW/ER
4.SEPARATED

HAIR

1. BLACK

EYES

1. BLACK

2. BROWN

2. BROWN

3. BLONDE

3. GRAY

4. GRAY

4. OTHERS

5. OTHERS (Specify)

BUILT

2. MEDIUM
3. HEAVY

1. LIGHT
2. FAIR
3. DARK

A WEARING CORRECTIVE LENSES.

B DRIVE ONLY WITH CUSTOMIZED VEHICLE

(Specify )

C DRIVE ONLY W/ SPECIAL EQUIPMENT FOR UPPER

BIRTHPLACE (City/Municipality, Province)

SAN PEDRO, LAGUNA

OR LOWER LIMBS

FATHER'S NAME (Family Name, First Name, Middle Name) indicate even if deceased

HERNANDEZ, BENONI, ERMITA

D DAYLIGHT DRIVING ONLY

E WITH HEARING AID

MOTHER'S NAME (Family Name, First Name, Middle Name) indicate even if deceased

HERNANDEZ, NIMFA, NEPOMUCENO

COMPUTATION OF FEES
APPLICATION FEE

SPOUSE NAME (Family Name, First Name, Middle Name) indicate even if deceased

EMPLOYER'S BUSINESS NAME

TEL NO.

N/A
EMPLOYER'S BUSINESS ADDRESS

N/A

AMOUNT
P

COMPUTER FEE
TOTAL

N/A

FILL THIS UP ONLY IF YOUR

NAME ABOVE IS DIFFERENT
FROM YOUR NAME IN
PREVIOUS LICENSE

CONDITIONS

COMPLEXION

1. LIGHT

LICENSE FEE
ADDITIONAL RESTRICTION CODE
CHANGE CLASSIFICATION
REVISION OF RECORDS
COMPUTER FEE
OTHERS (SPECIFY)
P

PREVIOUS NAME (Family Name, First Name, Middle Name)

THIS IS TO CERTIFY THAT

THE INFORMATION I HAVE
GIVEN IS TRUE AND
CORRECT.

QR-OPD-ADL R-1 03/01/10

TOTAL

THIS IS TO CERTIFY THAT I HAVE CAREFULLY EVALUATED THIS

APPLICATION INCLUDING THE SUPPORTING DOCUMENTS

IESOUS SHALOM N. HERNANDEZ

SIGNATURE OF APPLICANT

PRINT NAME/SIGNATURE

ROAD TEST SCORE SHEET

INSTRUCTIONS: AN APPLICANT HAS 100 POINTS AT THE START OF THIS TEST. A NUMBER OF POINTS IS
DEDUCTED FOR ERRORS COMMITTED. PASSING SCORE IS 70.
THE TEST WILL
IMMEDIATELY BE DISCONTINUED AND COUNTED AS FAILURE UNDER THE FOLLOWING
CONDITIONS.
1. STRIKING ANOTHER CAR
2. STRIKING A PEDESTRIAN
3. STRIKING ANY FIXED OBJECT

4. IMPROPER ACTION CAUSING

COLLISION OR NEAR
COLLISION OF OTHER
VEHICLE

1.

PRE DRIVING CHECK UP

1.1 CHECK TIRES AND BATTERIES
1.2 CHECK/CLEAN/ADJUST MIRRORS, LIGHT AND WINDSHIELD
WIPER
1.3 USE OF SEATBELT/ HELMET
1.4 CHECK HAND AND FOOT BRAKE
1.5 DISENGAGE CLUTCH WHEN STARTING ENGINE
2. DRIVING SKILLS
2.1 STEERING
2.1.1
POSITION OF HANDS
2.1.2
SMOOTHNESS
2.1.3
TWO HAND GRIP
2.1.4
OVERSTEERING
2.2 ENGINE CONTROL 2.2.1
USE OF GEAR
2.2.2
CHOOSE OF GEARS
2.2.3
USE OF CLUTCH
2.2.4
USE OF ACCELERATOR
2.3 USE OF BRAKES
2.3.1
APPLY BRAKES SMOOTHLY
2.3.2
REACTIONS TO HAZARDS
2.3.3
VEHICLE TURNING
2.4 SPEED CONTROL
2.4.1
OBSERVE SPEED LIMIT
2.4.2
NEEDLESS STOPS
2.4.3
OBSERVANCE TO TRAFFIC
RULES
2.5 TURNING LEFT,
2.5.1
TAKES PROPER LANE
TURNING RIGHT
AND U-TURN
2.5.2
SIGNAL INTENTION
2.5.3
USE OF HAND AND LIGHT SIGNAL
2.5.4
SWINGS TOO WIDE AND CUTS
TOO SHORT
2.6 BACKING
2.6.1
NUMBER OF ATTEMPTS
2.6.2
CONTROL OF VEHICLE/TRAILER
2.7 PARKING
2.7.1
NO. OF ATTEMPTS
3. OBSERVANCE TO TRAFFIC RULES
3.1 RIGHT OF WAY TO 3.1.1
WHILE APPROACHING
OTHER VEHICLES
INTERSECTION
3.1.2
IN CHANGING LANES
3.1.3
IN PASSING/BEING PASSED
3.2 STOP
3.2.1
OBEY TRAFFIC SIGNS
LIGHTS/SIGNALS
& OTHERS
3.2.2
POSITION AFTER STOPPING
3.2.3
MAKING FULL STOP WHEN
NECESSARY
3.2.4
ANTICIPATING BEFORE SIGNAL
CHANGES
3.2.5
EXERCISE DUE CARE FOR
PEDESTRIAN
3.3 RIGHT OF WAY
3.3.1
FOR OTHER VEHICLES
3.3.2
FOR PEDESTRIAN
3.3.3
FOR EMERGENCY
3.3.4
YIELDING OF RIGHT OF WAY
3.3.5
FOR BICYCLIST

TOTAL
DRIVING SKILLS RATER

DATE

PRINT NAME/SIGNATURE

COMMENTS / RECOMMENDATION

MAKE & TYPE OF MOTOR VEHICLE USED

TOTAL EQUIV.
DEMERIT
POINTS WEIGHT
10
2
2

TOTAL

DEMERIT

TOTAL

DEMERIT

TOTAL

2
2
2
50
2
2
2
2
2
2
2
2
3
3
3
3
2
4
2

2
2
4
2
2
2
40
5
3
3
4

4
2
3
3
3
3
3
2
2

100

100

CHIEF PRACTICAL EXAMINER

PLATE NO.

PLATE NO.

PLATE NO.

PRINT NAME/SIGNATURE

RECOMMENDED RC/S

APPROVED / DISAPPROVED
HEAD OF LICENSING CENTER

PRINT NAME/SIGNATURE