UNDERTAKING FOR DUPLICATE DRIVING LICENCE

To
The Licensing Authority-cum-
Regional Transport Officer,
------------------------------------

I ______________________________________S/o____________________________________
Residing at ________________________________________________________________________
do hereby solemnly affirmed and sincerely state as follows.

I am the holder of driving licence (D.L.Number)____________________________________________

Issued on___________________to drive Non-Transport (class of vehicle) issued on ______________
and Transport Vehicle (class of vehicle) issued on _________________ valid upto________________

The mentioned Driving Licence was lost, in spite of all effort, it could not be found. The lost
information was reported to ______________________________ police station and obtained the
LOST Document Report through on-line and same is enclosed.

I state that I am not involved in any cases such as Driving at a speed exceeding the specified limit, red
light jumping, carrying overload in goods carriages/carrying persons in goods carriages, driving
vehicles under the influence of drink and drugs and using mobile phone while driving a vehicle which
is laid down in Hon’ble Supreme Court committee’s view. My driving licence has not been seized by
any one of the government authority such as Police, Transport, Fores, PWD & PDS Officials etc. I also
submit that I have not involved in any accident cases including fatal accidents (304A IPC).

In case, if I get my original Driving Licence, I shall undertake to surrender the same in the Regional
Transport Office, _______________________ I hereby undertake full responsibility and risk on
obtaining this Duplicate Driving Licence.

I state that the above statement is true and correct to the best of my knowledge and belief, This
undertaking is to be produced before the Regional Trasport Officer,___________________________

SIGNATURE OF THE DEPONENT

PHOTO WITH NOTARY ATTESTATION (WITH PLACE AND DATE)