XLS《2申请表正面》

"附件1" "机动车驾驶证申请表(期满换证) 受理岗签字签章"档案编号",,

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"510300XXXXXX" "申请人信息","姓名","王小二"性别",,

"男",,

"出生日期",,

,"08-09-92",,

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"国籍",,

"中国" ,"身份证明名称","居民身份证",,

"号码",,

"5","5","5","5","5","5","5","5","5","5","5","5","5","5","5","5","5","5","照片" ,,

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"号码" ,"邮寄地址","四川省自贡市大安区盐都大道8号" ,"固定电话","8888888"电子信箱",,

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"wangxiaoer@163.

com" ,"移动电话","139XXXXXXXX"邮政编码",,

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"643000" "申请业务种类","初次申领",,

,"申请的准驾车型代号"属于持军警驾驶证、境外驾驶证申领的,还应填写所持驾驶证种类: ,"增加准驾车型" ,"持军警驾驶证申领"军队驾驶证武警驾驶证" ,"持境外驾驶证申领"香港驾驶证澳门驾驶证台湾驾驶证外国驾驶证" ,"证件损毁换证转入换证有效期满换证"换证时无法提交居住、暂住证明原因: ,"达到规定年龄换证自愿降低准驾车型换证"申请的准驾车型代号" ,"信息变化换证",,

,"变更事项"变更内容" ,"补证",,

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,"原因","丢失其他" ,"注销",,

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"本人申请死亡身体条件不适合丧失民事行为能力其他" ,"注销恢复",,

"准驾车型代号",,

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"超过有效期一年以上未换证被注销未满两年未按规定提交体检证明被注销未满两年" ,"延期换证延期提交身体条件证明",,

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"服兵役出国(境)其他" "申请方式",,

,"本人申请监护人申请委托代理申请" "委托代理人监护人信息",,

,"代理人/监护人姓名",,

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"身份证明名称"身份证明号码" ,,

,"联系地址"联系电话" "申告的义务和内容","机动车驾驶证申请人应当如实申告是否具有下列不准申请的情形:申请人及代理人对申请材料的真实有效性负责. ,"

一、器质性心脏病、癫痫病、美尼尔氏症、眩晕症、癔病、震颤麻痹、精神病、痴呆以及影响" ,"肢体活动的神经系统疾病等妨碍安全驾驶疾病;

申请人签字:王小二" ,"

二、吸食、注射毒品、长期服用依赖性精神药品成瘾尚未戒除;

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三、提供虚假申请材料,以欺骗等不正当手段申领机动车驾驶证;

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四、被吊销机动车驾驶证未满两年;

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五、造成交通事故后逃逸被吊销机动车驾驶证;

2010年04月01日" ,"

六、驾驶许可依法被撤销未满三年;

代理人/监护人签字: ,"

七、机动车驾驶证被暂扣;

,"

八、法律和行政法规规定的其他不准申请的情形. ,"上述内容本人已认真阅读,本人不具有所列的不准申请的情形.年月日" ,"填表说明",,

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一、使用黑色、蓝色墨水笔,用中文填写,字体工整,不得涂改;

二、标注有""符号的为选择项目,选择后在""中划"√";

三、"申请人信息"中包含的各栏均应认真填写,不得空项.其中:

1、"身份证明名称",属于居民的,填写"居民身份证"或者"临时居民身份证"和证件号码,在暂住地居住的内地居民还要填写公安机关核发的居住、暂住证明名称和证明号码;

属于香港、澳门特别行政区居民的,填写香港、澳门特别行政区"居民身份证"和证件号码;