MA Assigned License/ID/Permit Number
GENERAL INFORMATION Please fill out form clearly in blue or black ink. License Class
Note: Applicants under the age of 18 who wish to obtain a class M (motorcycle) license or endorsement must complete the Massachusetts Rider Education Program (MREP) and may not book a road test with the RMV. For additional information, please refer to the MassDOT RMV Division's website at www.massrmv.com. Month
Date of Birth
#M #F 5
Mailing Address (Where you want us to send your Driver's License and future notices from the RMV) U.S. Post Office MAY NOT deliver if your name is NOT on the mailbox.
Pleasant Street 93 D
Residential Address (Where you actually reside)
! Same as above
Melrose / MA
Pleasant Street 93 D
Melrose / MA
PARENTAL CONSENT FOR MINOR; Information & Certification of Person Providing Consent 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 1/2 years of age, and that my consent is given as required by M.G.L. Chap. 90, Section 8 for the issuance of a Driver's License. I further certify by my separate signature that the applicant has completed the required number of hours of behind-the-wheel driving by a validly licensed person aged 21 or over, with at least one year of driving experience, in addition to the requirements of the driver education and training program. (Sign the appropriate time period and sign again at the bottom where noted). • The applicant has completed the additional 40 hours of required supervised driving. __________________________________ Parent/Guardian Signature
• Completion of Skills Program: The applicant has completed the additional 30 hours of required supervised driving and successfully completed an RMV approved driver skills development program. __________________________________ Parent/Guardian Signature False certification is punishable by fine, imprisonment, or both (M.G.L. Chap. 90, Section 24). Parent/Guardian Address Parent/Guardian Signature Printed Name If the person giving consent IS NOT a parent, proper documentation of authority must be shown. 2. !Yes !No Are you currently taking any medication that may affect your ability to safely operate a motor vehicle? Note: If you answered yes to questions 1, or 2 an RMV Branch Representative must contact the Medical Affairs Branch(MAB).
1. !Yes !No Do you have any medical condition that may affect your ability to safely operate a motor vehicle? (The RMV’s Medical Advisory Board has established standards to determine fitness to operate a motor vehicle. Ask an RMV Branch Representative for a summary of these standards or visit our website at www.massrmv.com for the complete list of these standards.)
SIGNATURE OF APPLICANT (application not complete without signature) 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 verified with the Social Security Administration. I have reviewed this completed Application Form and swear (affirm), under the penalties of perjury, that the information I have provided is true and complete. False statements are punishable by fine, imprisonment, or both (M.G.L. c 90 §24)....