Commercial Driver'S License Application And Renewal Form Page 2
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1
2General Questions (Complete All Fields)
1.
Are you a Rhode Island resident?
8.
Are you a US Citizen?
YES
NO
YES
NO
2.
Do you want to register as an Organ and Tissue Donor?
YES
NO
9.
Do you want to Register to Vote?
YES
NO
(applicable to U.S. citizens only)
3.
Is your license or right to operate a vehicle currently
YES
NO
suspended, revoked, or refused by this or any other
PARTY AFFILIATION: ___________________________
state?
4.
Do you have any conditions (other than eyesight)
If you are 18 years old on or before Election Day you may
YES
NO
that could impair your ability to drive a motor vehicle?
register. If you are at least 16 years of age, you may
pre-register.
If yes, list any: _________________________________
5.
Have you ever been convicted of a motor vehicle
10.
Are you disqualified from operating a commercial
YES
NO
offense in District or Superior Court?
YES
NO
vehicle by Federal DOT regulations?
If yes, please explain: __________________________
NOTICE TO MALES 18 TO 26 YEARS OF AGE:
____________________________________________
Pursuant to RI Gen. Laws 31-10-47(a), “(a)ny male, United States
6.
Do you use any type of corrective lenses while driving?
YES
NO
citizen or immigrant who is at least eighteen (18) years of age,
7.
Have you ever held a license in any other state?
but less than twenty-six (26) years of age shall be registered
YES
NO
in compliance with the requirements of section 3 of the "Military
If yes, what is the most recent state? ____________
Selective Service Act", 50 U.S.C. App. 451 et seq., when applying
to receive a driver's license, renewal or identification card or
License Number:______________________
renewal.”
Exp. Date: _____________
Pursuant to RI Gen. Laws 31-10-47(b), the applicant recognizes
Endorsements: _______________________________
that by submitting this application he is consenting to registration
with the Selective Service system, if so required by federal law.
Restrictions: _________________________________
CDL History
As part of my application, I swear or affirm that I have held a license to operate any time of motor vehicle within the last ten (10) years in the
following states, for the following periods of time, under the following names:
STATE
LICENSE NUMBER
DATES LICENSE WAS HELD
NAME AT THAT TIME
I certify that I meet qualification requirements in Section 391 of the Federal Motor Carrier Safety Regulations.
I certify that the vehicle I operate of expect to operate is representative of the class of license applied for.
It is a misdemeanor to knowingly make any false statement to a public official and is punishable by fines up to $1,000.00 or up to one year
in jail, RIGL §11-18-1. Also, any false statements on your application could result in the revocation of your license, RIGL §31-11-1.
I, the undersigned, hereby make application for either a commercial driver’s license, permit, renewal, endorsement, or change state-of-record,
and declare under penalty of perjury that all statements made on this application are true and complete to the best of my knowledge and
belief.
Personal information contained in your motor vehicle records will be disclosed only if the state has obtained the express consent of the
person to whom such personal information pertains
DO YOU CONSENT TO SUCH DISCLOSURE?
YES
NO
Signature of Applicant
Applicant’s Printed Name
Date
DO NOT COMPLETE – FOR DMV USE ONLY
CLERK #: __________
10-YR HISTORY APPROVAL DATE: _______________
RES: _______________
END: _______________
License issuance under Skills Test Exemption
With corrective lenses?
PASS
FAIL
YES
NO
Opted not to renew HazMat
Without corrective lenses?
PASS
FAIL
YES
NO
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