Birth Day Month Year Driver number (if available) a) My application is for a driving licence/learner permit as a driver of a (see page 2 for vehicle categories). Group 1 Yes No Group 2 Yes No Yes No Yes No b) Has your most recent licence/permit been revoked or have you been advised by a medical professional to cease driving for a period? If yes state reason c) Have you ever had an epileptic seizure? If yes give the date of your last seizu.
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