Class D, M, Or D/m License And Id Card Application Form printable pdf download

Massachusetts

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

Registry of

Motor Vehicles

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 Liqour ID cards cannot be converted from other states. Permits and Liquor ID cards cannot be renewed.

Learner’s Permit Exam

License

Mass ID Card

Liquor ID Card

Permit

Issuance

Renewal

Change of Information

Duplicate

Out-of-State Conversion

Fees are payable by Check, Money order, MasterCard, Visa, American Express or Discover. Go online to for additional payment options.

PLEASE FILL OUT FORM CLEARLY IN BLACK OR BLUE INK

If paying by check, make payable to “Registry of Motor Vehicles” or “RMV.”

IDENTIFICATION REQUIREMENTS

For most transactions, including license conversions, applicants over the age of 18 must

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.

present three forms of ID which include:

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

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

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

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

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

guardian must sign the certification on the back of this application.

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

“Acceptable Forms of Identification” that may satisfy those requirements. The list is also on our website at www/mass.gov/rmv.

Social Security Number

License Class

MA Assigned License/ID/Permit Number

D/M*

*D & M permits require separate applications

GENERAL INFORMATION

Last Name

First Name

Middle Name

Date of Birth

Sex

Height

Month

Day

Year

Feet

Inches

Mailing Address

(

Where you want us to send your Driver's License/ID card and future notices from the RMV)

City/State

Zip Code

U.S. Post Office MAY NOT deliver if your name is NOT on the mailbox.

Residential Address

Zip Code

City/State

(Where you actually reside)

Same as above

REQUIRED INFORMATION

Questions 1 & 2 to be completed by all applicants. Questions 3-7 to be completed by License/Permit applicants only.

Yes

Do you want to be, or continue to be, an organ or tissue donor?

Is your license or RIGHT to operate suspended, revoked, canceled,

Yes

If yes, the RMV will print the designation on your driver's license/ID card.

withdrawn, or disqualified here or in another state, country, or jurisdiction?

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

Parent/Guardian Certification: I hereby certify that I give permission for the

If yes, where?

Exp. Date

applicant named above to register as an organ or tissue donor.

If yes, why?

Parent/Guardian Signature

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

Yes

Are you an active duty member of the U.S. armed forces?

Yes

Do you have any medical condition that may affect your ability to

safely operate a motor vehicle?

Yes

Are you currently licensed to drive in any state, country, or

jurisdiction?

(The RMV’s Medical Advisory Board has established standards to deter-

If yes, where? ____________________________________________

mine fitness to operate a motor vehicle. Ask an RMV Branch Representa-

tive for a summary of these standards or visit our website at

What class or type of license? _______________________________

rmv for the complete list of these standards.)

Yes

In the past 10 years, have you held any class of driver's license in any

Yes

Are you currently taking any medication that may affect your ability to

other state, country, or jurisdiction?

safely operate a motor vehicle?

If yes, where?

Class of License

License #

Note: If you answered yes to questions 6, or 7, an RMV Branch

________________________

________

________________________

Representative must contact the Medical Affairs Branch (MAB).

________________________

________

________________________

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

The RMV is required by law to provide certain information identifying organ donors to federally-designated organ procurement organizations

and other federally registered non profit eye and tissue banks serving the Commonwealth.

OUT-OF-STATE LICENSE/PERMIT CONVERSION

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

License/Permit Number

State

License/Permit Class

Expiration Date

Issue Date

(month/day/year)

D/M

Passenger Motorcycle

Both

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

RMV USE ONLY:

Date:

Initial:

Vision:

Pass

Fail

PAYMENT TYPE:

Cash

Credit Card

Check

Money Order

BATCH NUMBER:

T21042_08.20.09

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

Class D, M, Or D/m License And Id Card Application Form

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