Driver Certificate Application Form printable pdf download

DEPARTMENT OF PUBLIC UTILITIES - TRANSPORTATION OVERSIGHT DIVISION

ONE SOUTH STATION – 5th Floor, BOSTON, MA 02110

Ph: (617) 305-3559 Web:

BUS DRIVER CERTIFICATE APPLICATION

Choose one item below, and enclose a money order or

Type or Use Black/Blue Ink Pen. Keep copies of all

check payable to Comm of MA/DPU:

submitted forms for your records.

[ ] Motor Bus Driver Certificate & Road Test - $60.00

1. License:_____________________________________

[ ] School Bus Driver Certificate & Road Test - $60.00

(Driver must have held a MA license for 3 consecutive

[ ] Motor Bus Driver Certificate only (driver has VALID CDL

years, otherwise, attach DRIVING and CRIMINAL records

with “P” endorsement; no Road Test required) - $40.00

from previous state/country.)

[ ] School Bus Driver Certificate Renewal - $40.00

[ ] 70+ Motor Bus Driver Certificate & Road Test - $40.00

2. Name:___________________________________________

[ ] 70+ School Bus Driver Certificate & Road Test - $40.00

3. Maiden/Alias

:______________________________________________

[ ] 70+ Motor Bus Driver Certificate Renewal - $20.00

[ ] 70+ School Bus Driver Certificate Renewal - $20.00

4. Address:________________________________________

[ ] Duplicate Motor Bus Driver Certificate - $20.00

_____________________________________________________________________________________

[ ] Duplicate School Bus Driver Certificate - $20.00

[ ] CDL Road Test Only - $20.00 (circle one: Air Brake /

5. Date of Birth:_____________________________________

Retest / CDL Upgrade)

6. Phone Number:___________________________________

A legible copy of DOT Medical Examination REPORT (not

CERTIFICATE) no older than 90 days (220 CMR 155.02)

7. Has your privilege/license to operate in Massachusetts

must be returned with this application.

been suspended or revoked during the past 5 years? Y/N.

Bus Company Name and Phone #:

THE FOLLOWING STATEMENT IS MADE UNDER THE

PENALTIES OF PERJURY:

_____________________________________________

*I understand that a Criminal Offender Record Information

(CORI) check will be conducted of my background for

Check any and all RESTRICTIONS:

convictions and pending criminal case information only and

[ ] Corrective lenses

that will not necessarily disqualify me. By my signature

[ ] Corrective hearing appliance

below, I acknowledge and consent to this initial CORI check

[ ] RESTRICTED TO DRIVING VEHICLES THAT

and understand that a new CORI check will be required

CARRY 14 PASSENGERS OR LESS

prior to each renewal (if a license is approved). The

[ ] DPU specific restrictions

information I have provided below is correct to the best of

my knowledge

For school bus driver certification, a certified school bus

driving INSTRUCTOR must sign below in accordance with

*__________________________________________________

the requirements of M.G.L. c. 90 § 8A.

Signature of Applicant and Date

Signature:________________________________________

License:_________________________________________

Total Driver Training Hours:__________________________

Print Name:______________________________________

DO NOT MARK BELOW THIS LINE - FOR DEPARTMENT USE ONLY

DATE APPLICATION RECEIVED__________________

PHYSICAL FORM CLEARED YES [ ] NO [ ]

CORI CLEARED

YES [ ] NO [ ] DATE________________

DRIVING RECORD CLEARED YES [ ] NO [ ] DATE________________

ASSIGNED TO INSPECTOR_____________________ DATE_______________

DATE TESTED____________________ PASSED [ ] FAILED [ ]

TEMPORARY LICENSE ISSUED YES [ ] NO [ ]

WAS CDL CLASSIFICATION DOWNGRADED YES [ ] NO [ ]

INSPECTOR'S SIGNATURE_____________________________________________

DPU CERTIFICATE ISSUED YES [ ] NO [ ] DATE______________________

Revised 05/31/16

Driver Certificate Application Form

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