Application Drivers License

Report
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)
PRESENT ADDRESS (No., Street, City/Municipality, Province)
TEL NO. / CP NO.
TIN
TO BE ACCOMPLISHED BY LTO PERSONNEL ONLY
NATIONALITY
GENDER (F/M)
HEIGHT(cm) WEIGHT(kg)
BIRTH DATE (MM/DD/YY)
LICENSE
NUMBER
RESTRICTION CODE
TYPE OF APPLICATION (TOA)
A. A. NEW
D. FOREIGN LIC. CONVERSION
CHANGE CIVIL STATUS
B. B. DELINQUENT/DORMANT
E RENEWAL
CHANGE NAME
F
CHANGE DATE OF BIRTH
LICENSE
C. CHANGE CLASSIFICATION
PROF TO NON-PROF
ADDITIONAL RESTRICTION CODE
G DUPLICATE
DRIVING SKILL ACQUIRED OR
WILL BE ACQUIRED THRU
1 STUDENT PERMIT
1 DRIVING SCHOOL
(DSA)
(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
5
AUTOMATIC CLUTCH ONLY ABOVE 4500 KGS. GVW
5 COLLEGE
6
ARTICULATED 1600 GVW AND BELOW
6 POST GRADUATE
7
ARTICULATED 1601 UP TO 4500 GVW
8
ARTICULATED 4501 GVW AND ABOVE (TRUCK - TRAILER)
3 HIGH SCHOOL
YES
ORGAN DONOR
BLOOD TYPE
VEHICLES ABOVE 4500 KGS. GVW
4
EDUCATIONAL ATTAINMENT (EA)
1 INFORMAL
2 NON-PROFESSIONAL
VEHICLES UP TO 4500 KGS. GVW
(MANUAL AND AUTOMATIC CLUTCH)
3
CHANGE ADDRESS
TYPE OF LICENSE APPLIED
(TLA)
FOR
MOTORCYCLE/MOTORIZED TRICYCLES /
E- BIKES (LSV) TRIKES (A-1)
2
OTHERS
H REVISION OF RECORDS
NON-PROF TO PROF
1
NO
CIVIL STATUS (CS)
1.SINGLE
2.MARRIED
3.WIDOW/ER
4.SEPARATED
HAIR
EYES
BUILT
1. BLACK
1. LIGHT
1. LIGHT
2. BROWN
2. BROWN
3. BLONDE
3. GRAY
2. MEDIUM
3. HEAVY
2. FAIR
3. DARK
4. GRAY
4. OTHERS
5. OTHERS (Specify)
CONDITIONS
COMPLEXION
1. BLACK
A WEARING CORRECTIVE LENSES.
B DRIVE ONLY WITH CUSTOMIZED VEHICLE
(Specify )
C DRIVE ONLY W/ SPECIAL EQUIPMENT FOR UPPER
BIRTHPLACE (City/Municipality, Province)
OR LOWER LIMBS
FATHER'S NAME (Family Name, First Name, Middle Name) indicate even if deceased
D DAYLIGHT DRIVING ONLY
E WITH HEARING AID
MOTHER'S NAME (Family Name, First Name, Middle Name) indicate even if deceased
COMPUTATION OF FEES
APPLICATION FEE
SPOUSE NAME (Family Name, First Name, Middle Name) indicate even if deceased
P
COMPUTER FEE
TOTAL
EMPLOYER'S BUSINESS NAME
TEL NO.
EMPLOYER'S BUSINESS ADDRESS
AMOUNT
P
LICENSE FEE
ADDITIONAL RESTRICTION CODE
CHANGE CLASSIFICATION
REVISION OF RECORDS
COMPUTER FEE
OTHERS (SPECIFY)
FILL THIS UP ONLY IF YOUR
NAME ABOVE IS DIFFERENT
FROM YOUR NAME IN
PREVIOUS LICENSE
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
P
THIS IS TO CERTIFY THAT I HAVE CAREFULLY EVALUATED THIS
APPLICATION INCLUDING THE SUPPORTING DOCUMENTS
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

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