FORM R.S. 4.6

Application for certificate of fitness

To,

I hereby apply for the issue of a certificate of Fitness as required by section 56 of the Motor Vehicles Act, 1988.

Registration mark of Vehicle

Name of Owner

Address of Owner

Place where the vehicle is ordinarily kept

Name of manufacturer of vehicle

Manufacturer's model, or if not known, wheel base

Type of Vehicle

Engine number

Chassis number

Authority by which granted

Date when certificate ceased to be valid

Reasons for cessation of validity

Reasons for not producing certificate of fitness

Date

Signature of thumb-impression of applicant