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    Exempted Fastag Application Blank

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    mathur_dev

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    © All Rights Reserved
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    Exempted Fastag Application Blank

    Uploaded by

    mathur_dev
    9 views1 page

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    Copyright:

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    9 views1 page

    Exempted Fastag Application Blank

    Uploaded by

    mathur_dev

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    EXEMPTED FASTAG VEHICLES SPECIALLY DESIGNED AND CONSTRUCTEDFOR USE OF A

    PERSON SUFFERING FROM PHYSICAL DISABILITY ONLY


    Government of India
    Ministry of Road Transport and Highways
    Transport Bhawan, 1, Parliament Street
    Standard Application format for Exempted Category FASTag
    Annexure-2

    APPLICATION FORM
    1. Name of the Applicant (in Block Letters) :
    2. Document (For Self-Identity Proof, For Authorized :
    Representative-Authorization Letter, as applicable)
    3. Exempted Category of Vehicle Code : 34 (Annexure-1)
    (as per Annexure – 1)
    4. Present Address with Telephone No. :

    5. Permanent Address with Telephone No : SAME AS ABOVE


    6. Mobile Number :
    7. E-Mail ID : -
    8. Details of Bank Account/E-Wallet (optional) : -
    9. Details of vehicle for the Exempted Category as mentioned in : PERSONAL
    Annexure 1*:-
    a) Ownership – Govt./Personal/Third Party PERSONAL
    b) Usage of vehicle – Official/Personal PERSONAL
    c) Vehicle Registration Number
    (Registration Certificate to be enclosed)
    10. Validity period requested (maximum 5 years) : 5 YEARS
    11. In case of M.P./MLA/MLC, the following additional information : -
    is to be provided
    a. Identity Card Number : -
    b. Constituency Name : -
    c. State of the Constituency : -
    d. Present tenure and date : -
    e. Vehicle No. at New Delhi (only Car/Jeep/Van) : Not applicable is respect of MLA/MLC
    Vehicle No. at respective Constituency (only Car/Jeep/Van) : (Vehicle RC Copy to be enclosed)
    Date (Signature and seal of applicant/Authorized Representative for categories as per Annexure “1”)
    (For Official Purpose)
    Remarks of RO – NHAI:

    Remarks of IHMCL:
    FASTag Validity: Pan India/Within State-
    *Note: For Annexure 1-Please refer to the SOP for exempted FASTag issued by MORTH
    List od Document: (Copy) Passport Photo / Aadhar Card / Disability Certificate / RTO Book / Car Photo Mobility Kit Fitting and Front side
    (SAIKA)
    nd
    Address – NHAI (R.O.) Gujarat, 235-2 Floor, Supermall-01, Above HDFC Finance, Infocity, Gandhinagar – 382007, Ph.: 079-
    40306838/40306839

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