APRIL 14.]
THE NEW ZEALAND GAZETTE.

(4) Any person who commits an offence against these
regulations, for which no other penalty is provided, shall be
liable to a fine not exceeding £50.

SCHEDULE.
[Form No. 1.
APPLICATION FOR A MOTOR-DRIVER'S LICENSE UNDER THE
MOTOR-VEHICLES ACT, 1924.
Any mis-statement in the following particulars renders the
applicant liable to a fine not exceeding £50.]
To the Clerk of the [Insert name of local authority to which
application is made.]
I HEREBY apply for the issue to me under the Motor-vehicles
Act, 1924, and the regulations thereunder, of a license to
drive a [Specify class or classes of motor-vehicle : Private
motor-car, trade motor, public motor-car, motor-coach,
motor-omnibus, motor-cycle, motor-cycle and side-car, or
road machine].
Full name of applicant (Mr., Mrs., or Miss):
Place of permanent residence (full address):
Usual postal address:
Occupation:
Situation of garage (if any):
Date, year, and place of birth:
Is the application in respect of any of the following types
of motor-vehicle, and if so, which ?
(a) A steam-vehicle;
(b) An electrically-controlled vehicle;
(c) A gearless vehicle; or
(d) A vehicle specially designed to meet a physical dis-
ability from which the applicant suffers.
Is applicant the holder, or has he [she] ever been the holder
of any license to drive a motor-vehicle? If so present the
most recent license for inspection, and hereon give concern-
ing it the following particulars:-
Name of authority by whom license was issued:
Year of issue:
Class of motor-vehicle:
Endorsements (if any):
Has applicant ever been refused a motor-driver's license?
If so, give particulars as to:
Name of authority to whom application was made:
Grounds of refusal:
Date of application:
Any other relevant particulars:
Has applicant ever been convicted of any offence arising
out of the driving of any motor-vehicle? If so, give par-
ticulars:-
What is applicant's experience of motor-driving? [Indicate
briefly the nature and extent of applicant's experience.]
I do hereby solemnly state to the best of my knowledge
and belief that the above particulars are correct, and that:-
[Delete such of the following clauses (a), (b), and (c) as are
not applicable.]
*(a) 1. My hearing, sight (with glasses if necessary), and
heart are normal.
2. I am not subject to epilepsy, fits, dizziness, or
fainting bouts.
3. I do not suffer from rheumatism in the limbs, so as
to affect my driving capabilities.
4. In the use of at least three out of four limbs I have
no disability such as to affect my capability in
controlling the motor-vehicle(s).
[or, I have no disability in the use of either arm such
as to affect my capability in controlling the motor-
vehicle, and my application is to drive a vehicle
specially designed to meet physical disability in
the use of my legs.]
5. I am not aware that I have any physical or mental
disability or infirmity such as is likely to affect
my efficiency as the driver of a motor-vehicle.
†(b) A medical certificate in the prescribed form is attached
of my fitness to drive a motor-vehicle, and I am the person
therein named.
†(c) A medical certificate in the prescribed form is attached
of my fitness to drive a public motor-car [or motor-omnibus],
and a certificate of character is also attached, and I am the
person therein respectively named.
Dated at this day of 19 .
[Signature of applicant]:

• Required in case of license to drive a private motor-car,
  trade motor, motor-cycle, motor-cycle and side-car, or road
  machine, unless medical certificate in form 3 is substituted:
  Otherwise not required.
  † Alternative to (a).
  † Required in case of license to drive a public motor-car or
  motor-omnibus: Otherwise not required.

989
[Form No. 2.
LICENSE TO DRIVE A MOTOR-VEHICLE.
Issued by the : [Name of local authority].
[Name], of [Address], [Occupation], is hereby licensed, pursuant
to the Motor-drivers Regulations, 1931, to drive a vehicle of
the class [or any of the classes] following, namely :-
Specify class or classes of vehicle to which license applies-
(i) private motor-car ; (ii) trade motor-car ; (iii) public
motor-car ; (iv) motor-coach ; (v) motor-omnibus ; (vi) motor-
cycle ; (vii) motor-cycle and side-car ; (viii) road-machine.
Specify also if license applies only to : (a) A steam vehicle ;
(b) an electrically-controlled vehicle ; (c) a gearless vehicle ;
(d) a vehicle specially designed for persons suffering from
physical disability, in that case identify its character.
This license is subject to the conditions endorsed hereon.
[To be deleted if no conditions are endorsed.]
I certify as follows :—

1. That the applicant was prior to the date hereof the
   holder of a license to drive a motor-vehicle of the class[es]
   above described ; or
2. That the applicant has passed the prescribed test and
   examination as to ability to drive a motor-vehicle of the
   class[es] above described.
   [Delete 1 or 2 as the case requires.]
   Subject to the Motor-vehicles Act, 1924, and the said
   regulations this license shall come into force on the
   day of , 19 , and remain in force until the 31st May,
   19 , and is operative throughout New Zealand.
   License fee : 5s.
   Dated at this day of , 19 .
   [Signature and office of officer authorized to issue license
   on behalf of local authority] :
   [Signature of licensee] :
   EXTENSION.
   The above-named licensee, having passed the tests pre-
   scribed in that behalf, is hereby authorized to drive a motor-
   vehicle of the class(es) following, namely :
   subject in all respects to the terms of the foregoing license.
   Dated at this day of 19 .
   [Signature and office of officer authorized to issue license
   on behalf of local authority] :
   [Signature of licensee] :
   ENDORSEMENTS.
   (To be printed on back of license.)
   Particulars as to Convictions in relation to Motor-driving.
   | Date of | Place. | Court. | Nature | Penalty. | Date |
   | Conviction. | | | of | | at which |
   | | | | Offence. | | Period of |
   | | | | | | Endorse- |
   | | | | | | ment |
   | | | | | | expires. |

[Form No. 3.
THE MOTOR-VEHICLES ACT, 1924.
Medical certificate (to accompany application for Motor-
driver's license, in applicant's option; not available on
application for license to drive a public motor-car or motor-
omnibus.)
I HAVE on this date personally examined [Name of applicant],
knowing him to be an applicant for a motor-driver's license
under the above Act for a vehicle other than a public motor-
car or motor-omnibus, and I hereby certify that in my opinion,
having all proper regard to the safety of passengers and of
the public generally, the applicant is mentally and physically
a fit and proper person to be granted a motor-driver's license
for a vehicle other than a public motor-car or motor-omnibus.
The results of my examination are as follows:—

1. Eyesight : He conforms to the standards laid down
   She in clause (3) of Regulation 5 of the
   Motor-drivers Regulations, 1930.
2. Hearing:
3. The respiration is [is not] natural, and the respiratory
   sounds and the resonance of the chest are normal [abnormal].
4. The pulsations of the heart are [are not] natural in
   rhythm and force, and its sounds are [are not] those of health.