4. SEPARATED
J. ENHANCEMENT OF DL
AT MT
LIVER
LUNGS
CORNEA
BONES
SKIN
THIS IS TO CERTIFY UNDER PENALTY
OF PERJURY THAT THE INFORMATION I
HAVE GIVEN IS TRUE AND CORRECT
BY SIGNING THIS FORM, I VOLUTARILY AUTHORIZE LTO TO ALLOW DISCLOSURE OF THE ABOVE
PERSONAL INFORMATION TO ANY AUTHORIZED GOVERNMENT AGENCY
_____________________________________
PRINT NAME AND SIGNATURE
(EVALUATOR)
PRINTED NAME AND SIGNATURE
CE HEAVY ARTICULATED VEHICLES - Articulated Commercial Vehicles with trailer GVW of more than
3500kgs
O3 Trailers with a maximum GVW excee ding 3500kgs, but not exceeding 10 000kgs.
O4 Trailers with a maximum GVW excee ding 10000kgs.
CONDITIONS
1 WEAR CORRECTIVE LENSES 2 DRIVE ONLY W/ SPECIAL EQUIPMENT FOR UPPER LIMBS/LOWER LIMBS
3 DRIVE CUSTOMIZED MOTOR VEHICLE ONLY 4 DAYLIGHT DRIVING ONLY 5 HEARING AID IS REQUIRED
FILL THIS UP ONLY IF YOUR
NAME ABOVE IS DIFFERENT
FROM YOUR NAME IN
PREVIOUS LICENSE
PREVIOUS NAME (Family Name, First Name, Middle Name)
TO BE ACCOMPLISHED BY LTO PERSONNEL ONLY
THIS IS TO CERTIFY THAT I HAVE CAREFULLY EVALUATED THIS
APPLICATION INCLUDING THE SUPPORTING DOCUMENTS
D BUSES, COACHES and OTHER PASSENGER VEHICLES
M3 Vehicles used for the carriag e of passengers, comprising more than 8 seats in addition to the driver's seat
and having a maximum GV W exceeding 5000kgs.
BE ARTICULATED PASSENGER CARS - Vehicles with trailer GVW of no more than 3500kgs.
O1 Trailers with a maximum GVW not ex ceeding 750kgs.
O2 Trailers with a maximum GVW excee ding 750kgs, but not exceeding 350 0kgs.
B M1 Vehicles used for the carriage of passengers and comprising not more than 8 seats in addition to the
driver's seat with GVW up to 5000kgs.
B1 M2 Vehicles used for the carriage of passengers, comprising more than 8 seats in addition to the driver's
seat with GVW up to5000k gs.
B2 LIGHT COMMERCIAL VEHICLES
N1 Vehicles used for the ca rriage of goods and having a GVW up to 3500kgs.
HEAVY
C HEAVY COMMERCIAL VEHICLES
N2 Vehicles used for the ca rriage of goods and having a max imum GVW exceeding 3500kgs bu t not
exceeding 12000kgs
N3 Vehicles used for the ca rriage of goods and having a max imum GVW exceeding 12000kgs.
LIGHT
A MOTORCYCLE
L1 Two wheels with a maximum design speed not e xceeding 50 kph
L2 Three wheels with a maximum design spe ed not exceeding 50 kph
L3 Two wheels with a maximum design speed exce eding 50 kph
A1 TRICYCLE
L4 Motorcycle with side cars with a maximum design s peed exceeding 50 kph
L5 Three wheels symmetrically arranged with a ma ximum design speed exceeding 50 kph
L6 Four wheels whose unladen ma ss is not more than 350kg with maximum design sp eed not exceeding 45 kph
L7 Four wheels whose unladen ma ss is not more than 550kg with maximum design sp eed not exceeding 45 kph
DRIVER'S LICENSE VEHICLE CATEGORY
EXISTING
APPLIED
FOR
VEHICLE CATEGORY
sv
NON
PRO
PRO
CLUTCH
TYPE
D. ADDITIONAL CODE OR CATEGORY
I1. CHANGE ADDRESS
ISSUE DATE
EXPIRY DATE
E. CHANGE OF DL CLASSIFICATION
I2. CHANGE CIVIL STATUS
K. CHANGE OF CLUTCH TYPE
F. EXPIRED DL WITH VALID FDL
I3. CHANGE NAME
B. RENEWAL
H. DROPPING OF CATEGORY OR ADD'L OR
REMOVAL OF DRIVING CONDITIONS
I5. Others
AGENCY CODE
C. CONVERSION OF FOREIGN DL
I. REVISION OF RECORDS
TYPE OF APPLICATION (TOA)
EMERGENCY CONTACT PERSON
EMERGENCY CONTACT ADDRESS
EMERGENCY CONTACT NO.
A. NEW
G. DUPLICATE
I4. CHANGE BIRTH DATE
EMPLOYER'S BUSINESS NAME
TEL. NO
EMPLOYER'S BUSINESS ADDRESS
3. WIDOWED
LICENSE CLASSIFICATION
APPLIED FOR (LCA)
DRIVING SKILL ACQUIRED FROM (FOR DL APPLICANTS ONLY)
HIGHEST EDUCATIONAL
ATTAINMENT (EA)
FATHER'S NAME(Family Name,First Name,Middle Name)(indicate even if deceased)
1 STUDENT-DRIVER'S
PERMIT (SP)
2 DRIVER'S LICENSE (DL)
3 CONDUCTOR'S
LICENSCE (CL)
1 DRIVING SCHOOL__________________________
INSTRUCTOR ______________________________
2 PRIVATE LICENSED PERSON with DL NO.
NAME ________________________________________
3 TESDA ___________________________________
INSTRUCTOR _______________________________
MOTHER'S NAME(Family Name,First Name,Middle Name)(indicate even if deceased)
SPOUSE NAME(Family Name,First Name,Middle Name)(indicate even if deceased)
ORGAN DONOR
BLOOD TYPE
YES NO
EYES COLOR
ALL
KIDNEYS
HEART
EYES
PANCREAS
CIVIL STATUS (CS)
BIRTHPLACE (City, Municipality, Province)
1. SINGLE
2. MARRIED
PRESENT ADDRESS (No., Street, City/Municipality,Province)
TEL.NO. / CP NO.
TIN
NATIONALITY
SEX (M/F)
BIRTH DATE(YYYY/MM/DD)
HEIGHT(cm)
WEIGHT(kg)
LICENSE
NUMBER
APPLICATION FOR
STUDENT DRIVER'S PERMIT / DRIVER'S LICENSE / CONDUCTOR'S LICENSE (APL)
INSTRUCTIONS
1. ACCOMPLISH THE FORM COMPLETELY
3. SUBMIT THIS FORM TO THE CSR/EVALUATOR TOGETHER WITH
THE REQUIRED SUPPORTING DOCUMENTS
2. PRINT DATA LEGIBLY IN CAPITAL LETTERS
NAME(Family Name, First Name, Middle Name)
Annex A
REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF TRANSPORTATION LTO FORM NO. 21
LAND TRANSPORTATION OFFICE
East Avenue, Quezon City No.
DISTRICT OFFICE ______ _____________________ _____
__ POSTGRADUATE
__ COLLEGE
__ HIGH SCHOOL
__ ELEMENTARY
