SCHEDULE 1
FORM MVA 5
FEDERAL REPUBLIC OF NIGERIA
VEHICLE CHANGE OF OWNERSHIP APPLICATION FORM
Form should be filled in capital letters)
LICENSING OFFICE……………………………………………………………
NAME OF REGISTERED OWNER……………………………………………
(Surname) (other names)
(Various Agencies, Diplomatic Missions, Government etc)…………………
ADDRESS …………………………………………………………………………
……………………………………………………………………………………..
TELEPHONE NO……………………………………………………………….
NEW OWNER
NAME……………………………………………………………………………
(Surname) (other names)
ADDRESS………………………………………………………………………..
DETAILS OF TRANSACTIONS
PURCHASE PRICE …………………… IN WORDS………………………….
MODE OF PAYMENT ………………………PURCHASE DATE……………
VEHCILE DETAILS
VEHICLE REGISTRATION NO……………………………………………….
PROOF OF OWNERSHIP CERTIFICATE NO……………………………….
MAKE …………………………………MODEL………………………………
COLOUR…………………………………………………………………………
(indicate colour combination where applicable)
TYPES OF USE…………………………….. ENGINE
NO……………………
CHASSIS NO ……………………………… ENGINE CAPACITY………….
NO OF
CYLINDERS ……………………………………………………………
INTENDED USE OF VEHICLE
PRIVATE ……………………………………
COMERCIAL……………………
COVERNMENT USE………. MILITARY /PARAMILITARY……………….
VEHICLE REGISTRATION BOOK NO………………………………………..
DECLARATION
(We declare that the information given above to the best of our knowledge is
complete and correct in all respect)
REGISTERED OWNER’S
NAME……………………………………………………….
SIGNATURE …………………………………
DATE…………………………………...
RIGHT THUMB
PRINT………………………………………………………………….
NEW OWNER’S
NAME ………………………………………………………………...
SIGNATURE…………………………………….
DATE………………………………..
RIGHT THUMB
PRINT …………………………………………………………………
FOR OFFICIAL USE ONLY
(Information cross checked and ascertained to be true
FEE PAID ……………………….. DATE ………………….
RECEIPT………………...
………………………………... DATE ……………………….
SIGNATURE…………..
Authorizing officer
SCHEDULE 1
MVA 6
FEDERAL REPUBLIC OF NIGERIA
MOTOR VEHICLE CHANGE OF COLOUR
APPLICATION FORM
This application can only be treated at the licencing office where the vehicle was
originally registered
LICENSING OFFICE ……………………………………………….
DATE……………
APPLICANT’S
NAME …………………………………………………………………..
(Surname) (Other Names)
ADDRESS ……………………………………………………………………………
……
(Licensing Office must be informed of Change in Address)
………………………………………………………… Tel.
VEHICLE DETAILS:
VEHICLE IDENTIFICATION NO………… YEAR OF MANUFACTURE………..
MAKE…………………………………
MODEL……………………………………….
TYPE……………………………………………………………………………………
…
(Bicycle/saloon/coupe/station wagon/pick up/truck/Bus
Omnibus/Tanker/Tractor/Others please specify)
REGISTERED
COLOUR………………………………………………………………..
(Indicate Colour Combination where Applicable)
VEHICLE PROOF OF OWNERSHIP CERTIFICATE NO.
(ORIGINAL COPY OF CERTIFICATE TO BE PRODUCED)
ENGINE NO……………………………… CHASSIS NO……………………………
ENGINE CAPACITY ……………………. NO OF CYLINDERS …………………..
INTENDED USE OF VEHICLE ………………………………………………………
NEW
COLOUR …………………………………………………………………………
(Indicate Colour Combination where Applicable)
DECLARATION
I declare that the information provided in this application is true and binding on me
Signature ………………….. Date…………………………. Right Thumb
print…………..
FOR OFFICIAL USE ONLY
FEE PAID……………………………….. IN
WORDS……………………………………….
RECEIPT NO. AND
DATE……………………………………………………………………
…………………………….. ……………………………………
Motor Licensing Officer Date
SCHEDULE 1
FORM MVA 7
FEDERAL REPUBLIC OF NIGERIA
MOTOR VEHICLE REPLAEMENT OF ENGINE
NOTIFICATION FORM
(This application can only be treated where the vehicle was originally registered)
LICENSING
OFFICE …………………………………………………………………….
DATE OF
APPLICATION……………………………………………………………….
APPLICANT’S
NAME…………………………………………………………………...
ADDRESS………………………………………………………………………………
….
…………………………………………………………………………………………
……
(Notify Licensing Office of any change of address)
VEHICLE
NO……………………………………………………………………………..
DETAILS OF PREVIOUS ENGINE:
YEAR OF MANUFACTURE……………MAKE…………………………….
MODEL……………………………………TYPE………………………………
COLOUR…………………………………. ENGINE NO……………………..
CHASSIS NO……………………………...ENGINE CAPACITY…………….
NO OF CYLINDERS …………………… PROOF OF OWNERSHIP REG NO.
INTENDED USE OF VEHICLE……………………………………………………
DETAILS OF NEW ENGINE:
PURCHASE PRICE …………………… PLACE OF PURCHASE………………….
ENGINE NO…………………………… ENGINE
CAPACITY……………………..
NO OF CYCLINDERS………………… INVOICE/RECEIPT NO…………………
DECLARATION:
I ……………………………………….. hereby declare that the information provided
in this Application is true and binding on me.
………………………….. …………………………….
Signature /Date Right thumb print
Official use only
Fee paid……………………………………… Receipt No……………………..
Date …………………………………………
Name of Licensing Officer /Approving Authority ……. Remarks …………….
Sign / Date………………………………………………………………………
SCHEDULE 1
FORM MVA 8
FEDERAL REPUBLIC OF NIGERIA
NATIONAL VEHICLE LICENCE
237739
ORIGINAL – To Vehicle Owner
EXPIRES DEC 20……
VEHICLE LICENCE
237739
Original – To Vehicle Owner Dec 20…..
Private
LAGOS PRIVATE PlaceNameplaceLAGOS PlaceTypeSTATE
OWNER’S NAME REGISTRATION No
ADDRESS CHASSIS No
REGISTRATION No.ENGINE No.
CHASSIS No POC No.
ENGINE No …………………… ……………….
VEHICLE MAKE TYPE
POC No VEHICLE COLOUR LICENCE FEE
VEHICLE MAKE TYPE NETWEIGHT
VEHICLE COLOUR LICENCE FEE WEIGHT OF LOAD AUTHORISED
TO CARRY
NETWEIGHT NO OF PERSONS AUTHORISED TO CARRY
……………… ……………………
Issuing officer authorizing officer
------------------------
WEIGHT OF LOAD AUTHORISED TO CARRY TOTAL N
No of person authorized to carry
Issuing officer authorizing officer
………………… ………………..
Previous No. Date
---------------- ---------------------
PREVIOUS No DATE
SCHEDULE 1
FORM 9
FEDERAL REPUBLIC OF NIGERIA
PROOF OF OWNERSHIP CERTIFICATE
FEDERAL REPUBLIC OF NIGERIA
(Uniform Licensing Scheme)
Proof of Ownership Certificate
Issued on
Plate No. Spec VIN A 1798787
State Lic Aren
Vehicle Make Model
Vehicle Type Colour
Chassis No. Engine No.
Purpose
Name of Owner
Address Title
SCHEDULE 1
FORM MVA 10
FEDERAL REPUBLIC OF NIGERIA
GENERAL SPECIAL TRADE LICENCE/RENEWAL OF DEALER’S LICENCE
APPLICATION FORM
1. NAME OF DEALER
(Block Letters)
2. ADDRESS (P.O.Box only must not be given
3. WHAT LICENCE ARE YOU APPLYING FOR?
4. DURATION OF LICENCE REQUIRED
5. ISSUE DATE
6. APPLICATION FOR RENEWALS ONLY
State Details or Previous No and Code
Licence No Licence Code
DATE ………………………….
SIGN ……………………………..
(Applicant)
7. TO BE COMPLTED BY MOTOR LICENSING AUTHORITY FOR NEW
TRADE LICENCE TRADE LICENCE COVERED BY THIS
APPLICATION …………………………………………
(Car Dealers, Mechanics,
Spare Parts Dealers,
Driving School Entrepreneur
LICENCE NO(S) ALLOCATED LICENCE CODE(S)
ALLOCATED
Office Stamp Signature of Licensing Officer
SCHEDULE 1
FORM 10 A
FEDERAL REPUBLIC OF NIGERIA
TRADE LICENCE APPLICATION FORM
(For Spare Parts Dealers)
APPLICATION
NAME………………………………………………………………………………………………
(Surname) (Other Names)
(Applicable to Firms and organizations list of partners or members of the company to
be attached)
ADDRESS………………………………………………………………………………………..
TEL ………………………………………
LOCATION OF STORE…………………………………………………………………...
STAND
BRAND OF SPARE PARTS YOU DEAL ON…………………………………..
…………………………… …………………………….. ……………………………
…
…………………………… …………………………….. ……………………………
…
…………………………… …………………………….. ……………………………
…
NAME OF COMPANY…………………………………………………………………….
DATE……………………………………………….
REG. NO…………………………...
(Copy of Certificate Attached)
VAT NO……………………………………………………………………………………
SOURCE OF SPARE PARTS
WITHIN NIGERIA………………………………………………………………………...
OUTSIDE NIGERIA……………………………………………………………………….
QUALIFICATION OR TRADE ACRUIRED
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………….
APPLICANT’S SIGNATURE AND DATE…………………………………
OFFICIAL USE ONLY
FEE PAID (N) ………………………………………………………………………………..
AUTHORIZING OFFICER…………………… SIGN…………………………………….
DATE…………………………………
OFFICIAL STAMP……………………………...
SCHEDULE 1
FORM MVA 10B
FEDERAL REPUBLIC OF NIGERIA
TRADE LICENCE APPLICATION FORM
(For Mechanic Workshop/Registration)
APPLICANT’S NAME…………………………………………………………………
(Surname) (Other Names)
(Applicable to Firms and organizations list of partners or members of the company to be attached)
ADDRESS………………………………………………………………………………...
TEL ………………………………………………………………………………………….
STATE ………………………………………………………………………………………
L.G.A………………………………………………………………………………………..
BUSINESS REG. NAME ……………………………………………………………
LOCATION OF BUSINESS SITE …………………………………………………...
(Attach copy of Workshop plan).……………………………………………………
TEL…………………………………………………………………………………………………..
REGISTRATION CERTIFICATE NO……………………………………………………
(Copy attached)
DATE OF INCORPORATION …………………………………………………………..
NAMES OF DIRECTORS/PARTNERS SIGNATURES
1. ………………………………………… …………………………………
2. ………………………………………… …………………………………
3. ………………………………………… …………………………………
4. ………………………………………… …………………………………
5. ………………………………………… …………………………………
6. ………………………………………… …………………………………
NAMES OF TECHNICAL STAFF QUALIFICATION
1. ………………………………………… …………………………………
2. ………………………………………… …………………………………
3. ………………………………………… …………………………………
4. ………………………………………… …………………………………
5. ………………………………………… …………………………………
.
DO YOU ENGAGE IN APPRENTICESHIP TRAINING? YES/NO
WHAT TYPE OF EQUIPMENTS/TOOLS DO YOU HAVE?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
WHAT TYPE OF SERVICE DO YOU OFFER?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
APPLICANT’S SIGNATURE………………………………………………
DATE………………………………………………………………………………….
FOR OFFICIAL USE ONLY
FEE PAID
N …………………………………………………………………………………………………….
AUTHORIZING OFFICER ……………………………………………………………..…
SIGN. ……………………………………………………………………………………………..
DATE ………………………………………….. OFFICIAL STAMP……………………
MARGINAL NOTE:
Suspension or Revocation:
1. The Authority may suspend or revoke the registration certificate and licence if fake spare parts are discovered in the business premises or are being sole by the owner of the licence and the Authority may direct the dealing of the business premises.
2. The owner of the suspended or revoked certificate and licence may appeal to any magistrate court
3. Where the Authority discovers substandard or fake spare parts he shall direct the removal of such spare parts from circulation.
4. If shall be an offence for any spare parts dealer not to be registered as stipulated under these Regulations.
SCHEDULE 1 REGULATION 19 (12) (C)
FORM MVA 10 C
FEDERAL REPUBLIC OF NIGERIA
MOTOR VEHICLE /MOTOR
REGISTRATION FORM
INSTRUCTION :
(i) The objective of this Vehicle Dealership Census is for statistics and regulatory
purpose
(ii) This Form is to be completed in triplicate
(iii) Where the space provided is inadequate, please attach additional sheet(s)
(iv) Completed Form should be return to the Sector Commander of the Federal
Road Safety Corps, of the registering State.
1. NAME OF
COMPANY…………………………………………………………….
2. ADDRESS OF
COMPANY………………………………………………………..
…………………………………………………………………………………
……
PHONE/E-MAIL
3. NAMES AND ADDRESS OF DIRECTORS
A. …………………………………………………………………………...
ADDRESS………………………………………………………………..
B. …………………………………………………………………………...
ADDRESS…………………………………………………………………
C. …………………………………………………………………………...
ADDRESS……………………………………………………………….
D. ……………………………………………………………………………...
ADDRESS………………………………………………………………….
E. …………………………………………………………………………...
ADDRESS………………………………………………………………….
4. Is the Company formally registered with Corporate Affairs Commission? Yes/
No
(a) If yes State Registration
Number……………………………………………………………………
(b) Date of Registration ………………………………………………………
5. Is the Company a member of any Trade Association? Yes / No
If Yes state the name and address of the
Association ……………………
…………………………………………………………………………
….
6. NAMES OF THE EXECUTIVE MEMBERS OF THE ASSOCIATION
…………………………………………………………………………...
ADDRESS………………………………………………………………..
…………………………………………………………………………...
ADDRESS…………………………………………………………………
…………………………………………………………………………...
ADDRESS……………………………………………………………….
……………………………………………………………………………...
ADDRESS………………………………………………………………….
7. Do you engage in sales of vehicle only? Yes No
If not what other services
8. Do you have a repair garage? Yes……………………
No………………………
If yes do you have qualified /trained technicians? Yes……………
No………….
A. Qualification of technicians
………………………………………………………………………….…………
………………………………………………………………………….…………
………………………………………………………………………….…………
………………………………………………………………………….…………
9. Do you deal in second hand vehicle only? Yes …………………..
No ………….
If yes what is the source of second hand market?
Imported ……………………….. Nigerian
used…………………………………
(a) Do you have a show room? Yes ………………………. No…………….
(b) What is the space occupied (approx. Sq. M………………………………
10. What brands do you deal in?
(a) ………………………………………………………………………….………
(b) ………………………………………………………………………….………
(c) ………………………………………………………………………….………
Others………………………………………………………………………………
11. What advice do you think will assist Government to improve trade in used
vehicles?
………………………………………………………………………….………
…
………………………………………………………………………….………
…
12. What is your stock volume per annum?
(a) Under 20
(b) 20 - 50
(c) 50 - 100
(d) 100 - 300
(e) 300 - 500
(f) 500 - 1,000
(g) 1,000 and above
13. Do you have Dealer’s Number Plats?
Yes…………………………………………
No …………………………………………………………………………………
If yes, how
many? ………………………………………………………………….
Provide your dealership Plate
code…………………………………………………
14. Do you keep records of the vehicles sold by your company (Duty Certificate
Engine and Chassis Number, etc) Yes …………………….. No…………………..
15. Are records computerized? Yes…………………………….
No………………….
DECLARATION:
I declare that the information provided in this form is to the best of my knowledge
correct and binding on me and will notify the appropriate authority of any change.
…………………………..
Signature and Company’s Stamp
SCHEDULE 1
FORM MVA 10D
FEDERAL REPUBLIC OF NIGERIA
DRIVING SCHOOL REGISTRATION FORM
1. DRIVING SCHOOL DETAILS
(i) NAME OF
SCHOOL………………………………………………………………
…………………………………………………………………………………………
……
(ii)
ADDRESS……………………………………………………………………………...
…………………………………………………………………………………………
……
TEL. ………………………
MOBILE
…………………… FAX ……………..…………
(iii) NAME OF
PROPRIETOR:………………………………………………………...
(iv) NAME OF CHIEF
INSTRUCTOR/INSPECTOR…………………………………
(v)
QUALIFICATION(S)………………………………………………………………
…………………………………………………………………………………
…… ……………………………………………………………………………
…………
2. FACILITIES
(i) DRIVING RANGE – AVAILABLE ……… NOT AVAILABLE ……………
(ii) INSPECTION – AVAILABLE …………… NOT AVAILABLE…………….
(iii) DEMOSTRATOR – AVAILABLE ……… NOT AVAILABLE……………..
(iv) LIST OF INSTRUCTOR AND QUALIFICATIONS
(a) ………………………………………………………………………………
(b) ………………………………………………………………………………
(c) ………………………………………………………………………………
(d) ………………………………………………………………………………
(e) ………………………………………………………………………………
(f) ………………………………………………………………………………
(v). COURSE OFFERED:
(a) ………………………………………………………………………………
(b) ………………………………………………………………………………
(c) ………………………………………………………………………………
(d) ………………………………………………………………………………
(e) ………………………………………………………………………………
(f) ………………………………………………………………………………
(VI) DURATION OF TRAINING
(vii) NO OF TRAINING SESSIONS
3. EQUIPTMENT:
(i) SIMULATOR (S) (NO. AVAILABLE)
(ii) DEMOSTRATION VEHICLE(S)
VEHICLE REG. NO
(a) ……………………………… ……………………………………
(b) ……………………………… ……………………………………..
(c) ……………………………… ……………………………………
(d) ……………………………… ……………………………………..
(e) ……………………………… ……………………………………..
(f) ……………………………… ……………………………………..
iii ANY OTHER FACILITY/EQUIPTMENT AVAILABLE:
……………………………………………………………………………………..
……………………………… ……………………………………………………..
I certify that the information given above are to the best of my knowledge correct and
true.
SIGN……………………………… DATE……………………………………….
FOR OFFICIAL USE ONLY
(i) PRELIMINARY INSPECTION:
FACILITIES ON GROUND
Facility/Equipment Up to standard required No up to standard required
Remarks
(ii) SUITABILITY OF DRIVING
SCHOOL ………………………………………….
…………………………………………………………………………………
……
(iii) SECTOR MVA OFFICER’S COMMENTS
Having inspected the above mentioned facilities, I hereby confirm that the
observations above are true
Name ………………………………………. Rank……………………….
Sign / Date …………………………………………………………………………
(iv) ZONAL MVA OFFICERS REMARKS
RECOMMENDED ……………………….. NOT
RECOMMENDED…...
Name ………………………………………. Rank……………………….
Sign / Date …………………………………………………………………………
DIRECTOR MVA’S RECOMMENDATIONS
RECOMMENDED ……………………….. NOT
RECOMMENDED…...
Name ………………………………………. Rank……………………….
Sign / Date …………………………………………………………………………
APPROVING AUTHORITY: CORPS MARSHAL AND CHIEF EXECUTIVE
APPROVED …………………………….. NOT APPROVED.
Name ………………………………………. Rank……………………….
Sign / Date ………………………………Official stamp…………………………
SCHEDULE 1
FORM MVA 11
FEDERAL REPUBLIC OF NIGERIA
APPLICATION FOR NATIONAL DRIVER’S LICENCE
(FRESH APPLICATION FORM)
(to be filled in triplicate)
CLASS OF LICENCE APPLIED FOR ……………………… e.g A,
B,C, ………………
ISSUING STATE ……….. LOCAL
GOVERNMENT…………………………………
NAME OF
APPLICANT ………………………………………………………………….
(Surname) (Other names)
CONTACT
ADDRESS ……………………………………………………………………
……………………….PHONE……………………………
(INCLUDE P.O.BOX NO IF AVAILABLE)
you are required by law to notify this office of ay change in address.
DRIVING TRAINING RECORD
DO YOU ATTEND DRIVING COURSES? YES
/NO …………………………………
IF YES,
SPECIFY…………………………………………………………………………
GIVE LEARNERS PERMIT NUMBER WHAT
ISSUE? ………(1st, 2nd, 3rd, etc)
DATE OF ISSUE ………………………………. EXPIRY
DATE……………………….
HAVE YOU EVER BEEN DISQUALIFIED FROM DRIVING YES
/NO ……………...
IF YES,
WHY ……………………………………………………………………………..
WHEN? …………………………………………………. FOR HOW
LONG……………
PERSONAL DATE
SEX: FEMALE /MALE………………… DATE OF BIRTH ………………..
20……..
AGE LAST BIRTHDAY ………………. YEARS day month
year
HEIGHT …. metre…… cm. DO YOU HAVE ANY FACIAL MARKS?
YES/NO …….
BLOOD GROUP (e.g. A+, O+
etc) ………………………………………………………
DO YOU REQUIRE GLASSES FOR DRIVING? YES /
NO ……………………………
ANY FORM OF DISABILITY? IF YES,
EXPLAIN …………………………………….
CERTIFICATE OF MEDICAL FITNESS (Attached /Not
attached) ……………………..
DECLARATION
I declare that the information provided in this application is true and binding on me. I
will notify the appropriate authorities of any change therein.
SIGNATURE AND THUMB PRINT OF APPLICANT
Sign within box Right Thumb only
NATIONAL IDENTITY CARD NUMBER (IF
AVAILABLE) ………………………….
DATED THIS ………………………….. DAY OF ………………………….
20 ……….
FOR OFFICIAL USE ONLY
(Testing Officer)
DRIVING TEST RESULT: PASS/FAIL ………………… DATE OF
TEST…………...
VISION TEST RESULT PASS/FAIL…………………. DATE OF
TEST…………...
TEST CERTIFICATE NO ……………………………………
DATE……………………
DOES APPLICANT REQUIRE GLASSES TO DRIVE:
YES/NO ………………………
Have you checked all the details given by this applicant?
YES/NO……………………….
Do you recommend issuing of Licence: YES/NO ….. IF YES, STATE
CLASS………….
SIGNATURE OF TESTING
OFFICER……………………………………………………
Licensing Officer
The issuance of the licence for the applicant is/is not approved and authorized by me:
Amount paid ………………….. Date ……………………………. Receipt
No ………….
SIGNATURE OF AUTHORIZING OFFICER
Sign within box
DATE …………………………. AUTHORIZATION
NUMBER ………………………
Information Processing Centre (IPC)
MOTOR –CYCLE PRIVATE COMMERCIAL
LICENCE NO. ALLOCATED (tick one only)
(ALPHANUMERIC CODE) LG
SECURITY CODE OF LICENCE ………………………Signature of Security
Officer
SCHEDULE 1
FORM MVA 12
FEDERAL REPUBLIC OF NIGERIA
APPLICATION FOR NATIONAL DRIVER’S LICENCE
(REPLACEMENT/RENEWAL FORM)
(to be filled in triplicate)
CLASS OF LICENCE APPLIED FOR ……………………… e.g A,
B,C, ………………
ISSUING STATE ……….. LOCAL
GOVERNMENT…………………………………
NAME OF
APPLICANT ………………………………………………………………….
(Surname) (Other names)
CONTACT
ADDRESS ……………………………………………………………………
……………………….PHONE……………………………
(INCLUDE P.O.BOX NO IF AVAILABLE)
You are required by law to notify this office of ay change in address.
PARTICULARS OF PREVIOUS LICENCE
NUMBER
CLASS ……………………
DATE OF FIRST ISSUE ………………………………. EXPIRY
DATE……………………….
HAVE YOU EVER BEEN DISQUALIFIED FROM DRIVING YES
/NO ……………...
IF YES,
WHY ……………………………………………………………………………..
WHEN? …………………………………………………. FOR HOW
LONG……………
PERSONAL DATE
SEX: FEMALE /MALE………………… DATE OF BIRTH ………………..
20……..
AGE LAST BIRTHDAY ………………. YEARS day month
year
HEIGHT …. metre…… cm. DO YOU HAVE ANY FACIAL MARKS?
YES/NO …….
BLOOD GROUP (e.g. A+, O+
etc) ………………………………………………………
DO YOU REQUIRE GLASSES FOR DRIVING? YES /
NO ……………………………
ANY FORM OF DISABILITY? IF YES,
EXPLAIN …………………………………….
CERTIFICATE OF MEDICAL FITNESS (Attached /Not
attached) ……………………..
DECLARATION
I declare that the information provided in this application is true and binding on me. I
will notify the appropriate authorities of any change therein.
SIGNATURE AND THUMB PRINT OF APPLICANT
Sign within box Right Thumb only
NATIONAL IDENTITY CARD NUMBER (IF
AVAILABLE) ………………………….
DATED THIS ………………………….. DAY OF ………………………….
20 ……….
FOR OFFICIAL USE ONLY
Licensing Officer
Amount paid ………………….. Date ……………………………. Receipt
No ………….
SIGNATURE OF AUTHORIZING OFFICER
Sign within box
The issuance of the licence for the applicant is/is not approved and authorized by me:
AUTHORIZATION
NUMBER ……………………………
SIGNATURE
OF …………………………………………..
CHIEF STATE LICENSING OFFICER
DATE ………………………………..
___________________________________
___
Information Processing Centre (IPC)
MOTOR –CYCLE PRIVATE COMMERCIAL
LICENCE NO. ALLOCATED (tick one only)
(ALPHANUMERIC CODE) LG
SECURITY CODE OF LICENCE ………………………Signature of Security
Officer
SCHEDULE 1
FORM MVA 13
FEDERAL REPUBLIC OF NIGERIA
APPLICANT DRIVERS’ MEDICAL /PHYSICAL EXAMINATION FORM
APPLICANT’S
NAME ……………………………………………………………………
SEX…………………
AGE……………………………..STATE…………….…………...
WEIGHT ………… ..HEIGHT ……………………….. DATE OF
BIRTH ……………..
_________________________________
MEDICAL EXAMINATION
AUDITORY - HEARING ABILITY: GOOD FAIR POOR
MUSCULOSKELETAL - PHYSICAL APPEARANCE
POSTURE GOOD POOR
DEFORMITY
UPPER LIMBS (NO OF FINGERS)………………………………
LOWER LIMBS (NO.OF TOES & SHAPE OF FEET)…………...
____________________________________
MENTAL STATE
FIT UNFIT
STABLE UNSTABLE
RATIONAL IRRATIONAL
SUMMARY OF FINDING ………………………………………...………………………
…………………………………………………………………………………………………..……
Name of Medical Officer Designation ………………………………….…………….…………………
Signature
Date
Official Stamp