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This page links to an example of a completed
form. This is the actual form with sample text added in each section.
You should make sure that your form relates to your circumstances. If you need more help to prepare your form, get legal advice. Do not try to file this sample form.
This sample form is provided in Word format.
Sample application notice - RMS licence - medical grounds (17.5KB)
For more information on completing this form, see Instructions for filling out an application notice - RMS licence appeal - medical grounds.