Free License and ID Update Form - Massachusetts


File Size: 44.4 kB
Pages: 2
File Format: PDF
State: Massachusetts
Category: Court Forms - State
Author: MKM
Word Count: 1,559 Words, 9,747 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.mass.gov/rmv/forms/21053.pdf

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Preview License and ID Update Form
Massachusetts Registry of Motor Vehicles License/ID Update Application r Change of Information r License Issue
License Class Applying For:

r Duplicate: (Check one) mLicense m Permit m Mass ID m Liquor ID r Reinstatement r Renewal: (Check one) mLicense m Mass ID
CDL Endorsements Applying For: (For Class A, B, OR C)

Check appropriate box:

qA qB qC qD qM

qAIR BRAKES q COMBO qHAZMAT q PASSENGER qTANK qDOUBLES/TRIPLES qSCHOOL BUS
Identification Requirements

Fees are payable by Cash, Check, Money Order, Mastercard, Visa, or Discover. If paying by check, please make payable to "Registry of Motor Vehicles" or "RMV".

For certain transactions, applicants over the Mastercard, Visa, or Discover. You must also please make payable to "Registry of Motor Vehicles" or "RMV" Fees are payable by Cash, Check, Money Order,age of 18 must present three If paying by check,produce your social security number (SSN) that the

RMV can verify with the U.S. Social Security Administration (SSA) as forms of ID which include: having been issued to you. · Proof of date of birth · Proof of signature If you do not have an SSN, an acceptable written denial notice not · Proof of Massachusetts residency more than 30 days old, from the Social Security Administration (SSA) Applicants under 18 years of age must only provide proof of date of birth. is required. You must also provide proof of an acceptable visa The parent/guardian must sign the certification at bottom. status, an I-94, and a current non-U.S. Passport. Please see the Driver's Manual for the identification requirements you must satisfy to obtain a license or ID 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.

General Applicant Information Please print neatly with a ball point pen in blue or black ink.
Social Security Number (SSN): MA assigned License/Permit/ID Number:

If you currently use your SSN as your license/permit/ID number, the RMV will automatically issue you a state assigned number. Federal Law prohibits use of your SSN on a License/Permit/ID.
Name: Last First Middle Sex: Date of Birth (month/day/year)

qM qF
Residential Address: (Where you actually reside) Street# Apt/Unit# City State State Zip Code Zip Code Mail Address: (Where you want us to send your Driver's License/ID and future notices from the RMV) Street# Apt/Unit# City

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

Change of Information (Leave this section blank if no changes)

q Check here if your name has changed. Please print your new name in the General Information section and your previous name below.
Previous Name: (Last, First, Middle) _______________________________________________________________________________

q Check here if the address in the General Information section reflects a change of Mailing Address. q Check here if the address in the General Information section reflects a change of Residential Address. q Check here if height has changed. Current height is ft.___ in.___ q Check here if gender designation has changed. Note: additional documentation will be required.
Change Gender Designation to: q Male qFemale

REQUIRED INFORMATION
1. Are you currently licensed to drive in any state, the District of Columbia, or a foreign country? qYes qNo If yes, where?___________________________________ What Class or type of license? __________________________________ 2. In the past 10 years have you held any class of driver's license in any other state, the District of Columbia, or a foreign country? If yes, where? If yes, why?

to be completed by all applicants

4. Is your license or RIGHT to operate suspended, revoked, canceled, withdrawn, or disqualified here or in any other state?

qYes qNo
Exp. Date

qYes qNo
If yes, where? __________________________ __________________________ __________________________ License Class License # ______ ____________________ ______ ______ ____________________ ____________________

5. Are you an active duty member of the U.S. armed forces?qYes qNo 6. Do you have any medical condition that may affect your ability to safely operate a motor vehicle? qYes qNo (The Medical Advisory Board has established standards to determine fitness to operate a motor vehicle. Ask a clerk for a summary of these standards or visit our website at www.mass.gov/rmv for the complete list of these standards.) 7. Are you currently taking any medication that may affect your ability to safely operate a motor vehicle? qYes qNo Note: If you answered yes to questions 4, 6, or 7, additional documentation may be required.

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

3. Do you want to be, or continue to be, an organ or tissue donor? qYes If yes, the RMV will print the designation on your driver's license/ID. Applicants under age 18 need consent from a parent/guardian. Parent/Guardian Certification: I hereby certify that I give permission for the applicant named above to register as an organ or tissue donor.
Parent/Guardian Signature

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.

Date: Initial: Vision: Pass q Fail q

(RMV USE ONLY) Cash q Credit Card q Payment Type: Check q Money Order q

Batch Number:

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

T21053-0509

Voter Registration to be completed by all applicants (Except at road test sites)
To register to vote in Massachusetts you must be: - a U.S. CITIZEN; and - a Massachusetts resident; and - at least 18 years of age or older on or before the next election. 1. Do you want to register to vote? q Yes q No 2. Check all that apply: · Check "Yes" if you want to register to vote, or you are changing your name or address and want to be registered to vote with this new information. Are you a citizen of the United States of America?

q Yes

q No

· Check "No" if you are currently registered to vote and do not want to change Will you be at least 18 years of age or older on or before the next election? your voter registration or do not want to register to vote. q Yes q No If you answered "yes," complete question #2 and read the Affirmation Section below. NOTE: If you answered "no" to either of these questions, do not complete question #3. You are not eligible to register to vote at this time.

3. Please indicate party enrollment or political designation (check one). q Democrat q Republican q Green-Rainbow q No Party (unenrolled) q 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 the Application Form, including the Voter Registration Section, and hereby apply for a license to operate motor vehicles or an ID card and swear (affirm), under the penalties of perjury, that the information I have provided in this application is true and, if I am changing my name, I am not doing so for a fraudulent purpose, and if I am renewing a CDL (Commercial Driver License), I meet the qualification requirements listed in Title 49 CFR Part 391 or 540 CMR 2.06 and 14.00. I understand that false statements are punishable by fine, imprisonment or both under Massachusetts General Law (MGL) Chapter 90, Section 24.

Signature: _________________________________________________________________________

Date:_________________________________

The Registrar reserves the right to cancel, revoke, or recall, any permit, license or ID if the Registrar determines that the applicant was not qualified for such permit, license, or ID. 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. until 5 p.m.

Official Notice: Massachusetts law requires persons convicted of a sex offense to register with their local police departments. For information, call 1-800-93MEGAN Please visit our website for more information at: www.mass.gov/rmv