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

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

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

Learner’s Permit Exam

Reinstatement

License

Mass ID Card

Liquor ID Card

Permit

Issuance

Renewal

Change of Information

Duplicate

Out-of-State Conversion

Fees are payable by Cash, 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 “MassDOT.”

IDENTIFICATION REQUIREMENTS

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

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.

must 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 .

Social Security Number

License Class

MA Assigned License/ID/Permit Number

D M 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

M F

Mailing Address

(

City/State

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

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 1-4 to be completed by all applicants. Questions 5-8 to be completed by License/Permit applicants only.

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

Do you want to be, or continue to be, registered as an

Yes

organ & tissue donor?

in any other state, country, or jurisdiction?

If yes, where?

Class of License

License #

If yes, the RMV will provide this information to federally-designated organ procure-

ment organizations serving the Commonwealth, and will print this designation on

________________________

________

________________________

your driver’s license/ID card.

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

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

Is your license or RIGHT to operate suspended, revoked,

Yes

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

canceled, withdrawn, or disqualified here or in another state,

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

country, or jurisdiction?

If yes, where?

Exp. Date

Parent/Guardian Signature

If yes, why?

Yes

Are you an active duty member of the U.S. Armed Forces?

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

Yes

If you are a veteran of the U.S. Armed Forces, do you want

Yes

Do you have any medical condition that may affect your ability

the word “VETERAN” printed on your license/ID? If you are

to safely operate a motor vehicle?

not a veteran, check “No.”

(The RMV’s Medical Advisory Board has established standards to determine fitness to

NOTE: If yes, proof of honorable discharge must be presented.

operate a motor vehicle. Ask an RMV Branch Representative for a summary of these stan-

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

dards or visit our website at for the complete list of these standards.)

Yes

or jurisdiction?

Yes

Are you currently taking any medication that may affect your

ability to safely operate a motor vehicle?

where?_____________________________________

Note: If you answered yes to questions 7, or 8, an RMV Branch Representative must

contact the Medical Affairs Branch (MAB).

class/type__________________________________

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 D/M

Passenger

Motorcycle

Both

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

RMV USE ONLY:

Date:

Initial:

CDL Downgrade: I understand that my CDL will be downgraded to a

Class D, M, or D/M license and I authorize the RMV to process this

transaction.

Customer Signature:

T21042_0414

— 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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