Fillable Printable Class D, M, or D/M License and ID Card Application - Massachusetts

Class D, M, or D/M License and ID Card Application - Massachusetts

Parent/Guardian Signature

License Mass ID Card Liquor ID Card Permit

Fees are payable by Cash, Check, Money Order, MasterCard, Visa, American Express or Discover. Go online to www.massrmv.com for additional payment

options. If paying by check, make payable to “MassDOT.” PLEASE FILL OUT FORM CLEARLY IN BLACK OR BLUE INK

Issuance Renewal Change of Information Duplicate Out-of-State Conversion

Learner’s Permit Exam Reinstatement

Class D, M, or D/M License and ID Card Application

— Please complete REQUIRED Voter Registration and SIGNATURE Section on reverse side —

T21042_0215

IDENTIFICATION REQUIREMENTS

For most transactions, including license conversions, applicants over the age of

18 must present three forms of ID which include:

• Proof of date of birth • Proof of signature • Proof of Massachusetts residency

Applicants under 18 years of age must only provide proof of date of birth. The

parent/guardian must sign the certication on the back of this application.

You must also produce your social security number (SSN) that the RMV can verify

with the U.S. Social Security Administration (SSA) as having been issued to you.

If you do not have an SSN, an acceptable written denial notice not more than 60

days old, from the Social Security Administration (SSA) is required. You must also

provide proof of an acceptable visa status, an I-94, and a current non-U.S. Passport.

Please see the Driver’s Manual for the identication requirements you must satisfy to obtain a license or ID card and the list of

“Acceptable Forms of Identication” that may satisfy those requirements. The list is also on our website at www.massrmv.com.

MA Assigned License/ID/Permit Number

Social Security Number

‑

D M D/M*

License Class

REQUIRED INFORMATION

Do you want to be, or continue to be, registered as an

organ & tissue donor?

If yes, the RMV will provide this information to federally-designated

organ procurement organizations serving the Commonwealth, and

will print this designation on your driver’s license/ID card.

Applicants under age 18 need consent from a parent/guardian.

Parent/Guardian Certication: I hereby certify that I give permis-

sion for the applicant named above to register as an organ or tissue

donor.

Are you an active duty member of the U.S. Armed Forces?

If you are a veteran of the U.S. Armed Forces, do you

want the word “VETERAN” printed on your license/

ID? If you are not a veteran, check “No.”

NOTE: If yes, proof of honorable discharge must be presented.

Are you currently licensed to drive in any state,

country, or jurisdiction?

where?_____________________________________

class/type__________________________________

In the past 10 years, have you held any class of driver’s

license in any other state, country, or jurisdiction?

(inform RMV of previous names) (use additional paper if you need more space)

Is your license or RIGHT to operate suspended, revoked,

canceled, withdrawn, or disqualied here or in another

state, country, or jurisdiction?

If yes, where? Exp. Date

If yes, why?

Note: If you answered yes, additional documentation may be required.

Do you have a cognitive, neurologic, physical, or any other

impairment that may affect your functional ability to oper-

ate a motor vehicle safely?

(The Commonwealth’s medical standards for safe operation of a motor

vehicle are found at http://www.massrmv.com/rmv/medical/policies.htm.)

Are you currently taking any medication that may affect

your ability to safely operate a motor vehicle?

1. Yes

2. Yes

3. Yes

4. Yes

Yes

Height

Last Name First Name Middle Name

Residential Address (Where you actually reside) Same as above

City/State

Zip Code

Mailing Address (Where you want us to send your Driver’s License/ID card and future notices from

the RMV). U.S. Post Ofce MAY NOT deliver if your name is NOT on the mailbox.

City/State

Zip Code

GENERAL INFORMATION

SexDate of Birth

M F

Month

Day Year

Feet

Inches

Please make your selection below. If you select one of the options from line 2, you must also select one of the options from line 3.

NOTE: Mass ID cards and Liquor ID cards cannot be converted from other states. Permits and Liquor ID cards cannot be renewed.

*D & M permits require separate applications

Date: Initial:

RMV USE ONLY:

Your out-of-state license/permit must be surrendered to the RMV.

License/Permit Number

OUT-OF-STATE LICENSE/PERMIT CONVERSION

State Expiration Date (month/day/year)

Passenger

Motorcycle

Both

License/Permit Class Issue Date (month/day/year)

If yes, where? Class of License License #

________________________ ________ ________________________

Note: If you answered yes to questions 7, or 8, an RMV Branch Repre-

sentative must contact the Medical Affairs Branch (MAB).

D/M

CDL Downgrade: I understand that my CDL will be downgraded to

a Class D, M, or D/M license and I authorize the RMV to process this

transaction.

Customer Signature:

Questions 1-4 to be completed by all applicants. Questions 5-8 to be completed by License/Permit applicants

to be completed by applicants converting an out-of-state license or permit

Check here if your name has changed. Please print your new name in the General Information section and your previous name below.

Check here if the address in the General Information section reects a change of Mailing Address.

Check here if the address in the General Information section reects a change of Residential Address.

Check here if your gender designation

has changed

Note: Additional documentation will be required.

Change gender designation to: Male Female

Check here if your height has changed. Current height is ft.___ in.___

CHANGE OF INFORMATION

Last Name

First Name

Middle Name

This section must be completed by a parent of the applicant, the legal guardian, the Massachusetts Child Guardian Division, or the Headmaster

of the Boarding School the applicant is attending.

To the Registrar: I hereby certify I am: (check one) parent legal guardian Massachusetts Child Guardian Division boarding school headmaster

of the above-named applicant who is less than 18 years of age, but not less than 16 years of age, if applying for a Learner’s Permit or Driver’s License OR who is less

than 18 years of age, but not less than 14 years of age, if applying for an ID card, and that my consent is given as required by M.G.L. Chap. 90, Section 8 for the issu-

ance of a Driver’s License; or as required by M.G.L. Chap. 90, Section 8B for a Learner’s Permit; or by M.G.L. Chap. 90, Section 8E for an Identication Card (ID).

False certication is punishable by ne, imprisonment, or both (M.G.L. Chap. 90, Section 24).

Parent/Guardian’s Address:

Parent/Guardian’s Signature: Printed Name:

If the person giving consent IS NOT a parent, proper documentation of authority must be shown.

PARENTAL CONSENT FOR MINOR; INFORMATION & CERTIFICATION OF PERSON PROVIDING CONSENT

FOR CUSTOMER SERVICE:

Contact our Phone Center at 857-368-8000 • Weekdays 9 a.m.- 5 p.m.

Please visit our website for more information at:

www.massrmv.com

OFFICIAL NOTICE:

Massachusetts law requires persons convicted of a sex offense to register

with their local police departments. For information, call 1-800-93MEGAN.

Other

SIGNATURE OF APPLICANT

Note: This application will be processed through the National Driver Register (NDR) and the Commercial Driver License Information System (CDLIS) to verify the

status of operating privileges in other jurisdictions and the social security number will be veried with the Social Security Administration.

I have reviewed this completed Application Form, including the Voter Registration Section, and hereby apply for a Learner’s Permit/

Driver’s License or an ID card and swear (arm), under the penalties of perjury, that the information I have provided is true and complete.

False statements are punishable by ne, imprisonment, or both (M.G.L. c 90 §24).

Signature: Date:

The Registrar reserves the right to cancel, revoke, or recall, any permit, license, or ID card if it is determined that the applicant was not qualied for such permit, license, or ID card.

If you are registering to vote, when you sign your name at the counter to complete this transaction, you will be swearing (arming) that you

are the person identied on this form; that the information on this form is true; THAT YOU ARE A CITIZEN OF THE UNITED STATES;

that you are not a person under a guardianship which prohibits you from registering to vote; that you are not temporarily or permanently

disqualied by law from voting because of corrupt practices with respect to elections; and that you consider the residential address recited

on this form to be your home address.

Condentiality of voter registration information: If you register to vote, the oce at which you submit your application will remain condential and will be used only for

voter registration purposes. If you decline to register to vote, the fact that you declined to register will remain condential and will be used only for voter registration purposes.

Penalty for illegal voter registration: Fine of not more than $10,000 or imprisonment for not more than ve years or both (M.G.L., Chap. 56 , Section 8).

AFFIRMATION TO BE READ BY APPLICANTS REGISTERING TO VOTE

To register to vote in Massachusetts you must be: A U.S. CITIZEN, a resident of Massachusetts and at least 18 years old on or before the next election in your city or town, which

could be a town meeting, city or town preliminary, city or town election, state primary, state election, special state primary, special state election, or special city or town election.

1. Do you want to register to vote? Yes No

•Check “Yes” if you want to register to vote, or you are changing your name

or address and want to be registered to vote with this new information.

• Check “No” if you are currently registered to vote and do not

want to change your voter registration

If you answered “yes,” complete question #2 and read the Armation Section below.

2. Check all that apply:

Are you a citizen of the United States of America?

Yes No

Will you be at least 18 years of age or older on or before Election Day?

Yes No

VOTER REGISTRATION

3. Please indicate party enrollment or political designation (check one).

Democratic Republican Green-Rainbow United Independent Party No Party (unenrolled)

Political Designation (not a political party):

(Print desired designation.)

PLEASE ASK THE LICENSE CLERK FOR YOUR VOTER REGISTRATION RECEIPT

NOTE: If you answered “no” to either of these questions, do not complete

question #3. You are not eligible to register to vote at this time.

Turning 21? Renew on or after your 21st birthday to receive a standard horizontal license.

If you change your address, you must notify the RMV within 30 days.

to be completed by all applicants

(application not complete without signature)