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