Class D, M, Or D/m License And Id Card Application Form (Page 2 of 2) in pdf

CHANGE OF INFORMATION

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

First Name

Last Name

Middle Name

Check here if the address in the General Information section reflects a change of Mailing Address.

Check here if the address in the General Information section reflects a change of Residential Address.

Check here if your gender designation has changed.

Note: Additional documentation will be required.

Other

Change gender designation to:

Male

Female

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

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 years of age, if applying for an ID card, Learner's Permit, or Driver's License, and that my consent is given

as required by M.G.L. Chap. 90, Section 8 for the issuance 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 Identification Card (ID).

False certification is punishable by fine, 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.

VOTER REGISTRATION to be completed by all applicants

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

2. Check all that apply:

• Check "Yes" if you want to register to vote, or you are changing your name or ad-

Are you a citizen of the United States of America?

Yes

dress and want to be registered to vote with this new information.

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

Check "No" if you are currently registered to vote and do not want to change

•

Yes

your voter registration

NOTE: If you answered "no" to either of these questions, do not complete question

If you answered "yes," complete question #2 and read the Affirmation Section below.

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

3. Please indicate party enrollment or political designation

(check one)

Democrat

Republican

Libertarian

No Party (unenrolled)

Political Designation (not a political party):

(Print desired designation.)

PLEASE ASK THE LICENSE CLERK FOR YOUR VOTER REGISTRATION RECEIPT

AFFIRMATION TO BE READ BY APPLICANTS REGISTERING TO VOTE

If you are registering to vote, when you sign your name at the counter to complete this transaction, you will be swearing (affirming) that you are the person identified 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 disqualified 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.

Confidentiality of voter registration information:

If you register to vote, the office at which you submit your application will remain confidential 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 confidential 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 five years or both (M.G.L., Chap. 56 , Section 8).

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, including the Voter Registration Section, and hereby apply for a Learner's Permit/Driver's License or an ID card 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).

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 qualified for such permit, license, or ID card.

Official Notice: Massachusetts law requires persons convicted of a sex offense

to register with their local police departments. For information,

call 1-800-93MEGAN.

For customer service: Contact our Phone Center at 617-351-4500 from the

339/617/781/857 area codes or 800-858-3926 from all other MA area codes.

Weekdays 9 a.m.- 5 p.m.

Please visit our website for more information at: