Fillable Application To Renew A School Bus Driver Certificate (Commonwealth of Massachusetts)

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Application To Renew A School Bus Driver Certificate (Commonwealth of Massachusetts)

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The Application To Renew A School Bus Driver Certificate (Commonwealth of Massachusetts) form is 5 pages long and contains:

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  • 4 check-boxes
  • 136 other fields

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Application to Renew a School Bus Driver Certificate
Registry of Motor Vehicles ● Vehicle Safety & Compliance Services
P.O. Box 55892 ● Boston MA 02205-5892
p.1 VSC108_0918
IMPORTANT: This application must be completed, signed, and dated. Incomplete applications will be returned.
A. Checklist
Renew Application:
Application must be filled out completely.
Application must be signed by the applicant and a current email address must be provided for future RMV correspondence.
All eight hours of in-service training must be completed before submitting the application.
Fees: $15.00 for one-year certificate; $7.50 for six-month certificate.
Enclose check or money order payable to MassDOT.
The transportation company that you are employed by, or expect to be employed by, must complete section B - Applicant Information.
Any applicant who has ever resided in another state or country and has relocated to Massachusetts must include with application:
Certified Out-of-State Driving Record effective within the preceding 90 days of application submission.
Certified Out-of-State Criminal Record Report effective within the preceding 90 days of application submission.
CORI Form:
CORI must be filled out completely and notarized.
CORI must accompany the application.
Medical Requirements:
Please provide the DOT Medical Examination Report form dated within 90 days of application submission.
The Medical Evaluation Form is Section G of this application. (Only if needed.)
Current Out of State Applicant:
Include Certified Out-of-State Driving Record effective within the preceding 90 days of application submission. Screen prints are not accepted.
Include Certified Out-of-State Criminal Record Report effective within the preceding 90 days of application submission.
Mail complete application to: Registry of Motor Vehicles
Vehicle Safety and Compliance Services, Attn: School Bus Driver Certificate
P.O. Box 55892
Boston, MA 02205-5892
An incomplete application will be returned. Save a copy of all submitted forms.
For questions, email RMVSchoolBus@state.ma.us or call Vehicle Safety and Compliance Services at 857-368-7310.
B. Applicant Information
Last Name First Name Middle Name Suffix
Date of Birth (MM/DD/YYYY) Driver’s License # Social Security Number Gender
M
F
License Class State of Issuance Expiration (MM/DD/YYYY) SB Certificate Expiration (MM/DD/YYYY)
Residential Address (Where you actually reside)
Street
Mailing Address
(same as above)
Email Phone Type Phone #
Cell
Home
Work
Employer Information
Employer Name Address
Employer Email Phone Type Phone #
Cell
Home
Work
Apt. #
City
State
Zip
Code
-
Street
Apt. #
City
State
Zip
Code
-
Street
City
State
Zip
Code
-
p.2 VSC108_0918
C. Certificate Type
One -year - $15
6-Month - $7.50 - Applicants who are over 70 years of age or are insulin-dependent, diabetic, or have had a hypoglycemic episode.
D. In-Service Training Requirements
An applicant who is renewing a school bus certificate shall complete a minimum of eight hours of in-service training as established and approved by
the Registrar prior to receiving the certificate. FOR SCHOOL BUS CERTIFICATION, a Certified School Bus Instructor must sign below in
accordance with the requirements of 540 CMR 8.03.
Certified School Bus Instructor Trainer’s License #
Email Address Phone #
Signature of School Bus Instructor:
Total Driver In-Service Training Hours
E. Certification and Signature of Applicant
I have reviewed this completed Application and affirm, under the penalties of perjury, that the information I have provided is true and correct. I am aware
that false statements are punishable by fine, imprisonment, or both under M.G.L. Chapter 90, Section 24B.
Applicant’s Signature _____________________________________________ Date _________________________
F. Medical Information and Applicant Signature
I hereby authorize the Licensed Physician completing this from to discuss and release any or all medical records pertaining to it content with or to
representatives of the Registry of Motor Vehicles.
Applicant’s Signature ___________________________________________________________ Date ________________________
G. Medical Evaluation Form (if needed)
Must be completed by a Licensed Physician, NOT a Nurse Practitioner or Physician Assistant
Last Name First Name Middle Name Suffix
Date of Birth (MM/DD/YYYY) Driver’s License #
1. Is the applicant currently diagnosed with having diabetes? ...................................................................................................................
Yes
No
2. Does the applicant have an Implanted Cardiac Defibrillator? ..............................................................................................................
Yes
No
If “YES” the applicant must submit a “Cardiovascular Medical Evaluation Form” completed by a medical doctor.
3. Distant Visual Acuity (Snellen): Left eye: (OS)20/ ______________ Right eye: (OD) 20/ ____________
Is the applicant insulin dependent? ..............................................................................................................................................
Yes
No
Has applicant ever had a hypoglycemic episode or spell? ............................................................................................................
Yes
No
If “YES” to either above, the applicant must submit a “Diabetes Medical Evaluation Form”
completed by a Board Certified or Board eligible medical doctor in Endocrinology.
Does the applicant use corrective lenses for driving?.............................................................................................................
.......
Yes
No
(If applicant uses corrective lenses for driving, please specify visual acuity above as corrected with Rx)
Combined horizontal peripheral field of vision must be NOT LESS THAN 120 combined (Record in degrees.): ___________
Is the applicant able to distinguish the colors red, green and amber? ...........................................................................................
Yes
No
p.3 VSC108_0918
4. Hearing: Can the applicant perceive a forced whispered voice in the better ear at not less than 5feet with or without
the use of a hearing aid or, if tested by use of an audiometric device, does not have an average hearing loss in the better
ear greater than 40 decibels at 500Hz, 1000 Hz, and 2000Hz with or without a hearing aid when the audiometric device
is calibrated to the American National Standard? .................................................................................................................................
Yes
No
5. Does the applicant have a Respiratory Disease/Disorder? ................................................................................................................
Yes
No
If “YES” does the applicant have an O2 saturation rate of greater than 88%, at rest or with minimal exertion,
with or without supplemental oxygen? ...................................................................................................................................................
Yes
No
6. Is the applicant currently diagnosed with Epilepsy? ...............................................................................................................................
Yes
No
7. Does the applicant have any loss or impairment of foot, leg, finger, hand, or arm likely to interfere with safe driving? .........................
Yes
No
8. Does the applicant have any other physical condition likely to interfere with safe driving? ......................................................................
Yes
No
9. Does the applicant have any mental, nervous, organic, or functional disease likely to interfere with safe driving? ............................
Yes
No
10. Does the applicant have any contagious or communicable diseases? ...............................................................................................
Yes
No
11. Is the applicant addicted to the use of narcotics or habit forming or tranquilizers or stimulants or the excessive
use of alcoholic beverages or liquors? ................................................................................................................................................
Yes
No
12. Please check ONE BOX below:
The patient named above IS medically qualified to operate a school bus and fulfill all of the
duties and responsibilities associated with such operation.
The patient named above IS NOT medically qualified to operate a school bus.
Additional Comments: _______________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
H. Physician Information and Attestation
Massachusetts NPI #
Last Name First Name Middle Name
Phone # Address
Street
Email
I hereby certify that the information provided herein is true, accurate and complete:
Physician’s Signature _________________________________________________________ Date: _______________________
City/
Town
Zip
Code
-
Criminal Offender Record Information
(CORI) Acknowledgment Form
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 |
p.4 CORI101_0218
To be used by organizations conducting CORI checks for employment or licensing purposes.
The Massachusetts Registry of Motor Vehicles is registered under the provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening
current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, or current licensees.
As a prospective or current employee, subcontractor, volunteer, license applicant or current licensee, I understand that a CORI check will be submitted
for my personal information to DCJIS. I hereby acknowledge and provide permission to the Massachusetts Registry of Motor Vehicles to submit a CORI
check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any
time by providing the Massachusetts Registry of Motor Vehicles with written notice of my intent to withdraw consent to a CORI check.
I also understand, that the Massachusetts Registry of Motor Vehicles may conduct subsequent CORI checks within one year of the date this Form was
signed by me.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.
__________________________________________________________________________ _______________________________
Signature of CORI Subject Date
Criminal Offender Record Information
(CORI) Acknowledgment Form
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 |
p.5 CORI101_0218
A. Applicant Information
Please complete this section using the information of the person whose CORI you are requesting. The fields marked with an asterisk (*) are required.
*First Name *Last Name Middle Name Suffix
Former Last Name #1 Former Last Name #2
Former Last Name #3 Former Last Name #4
*Date of Birth (MM/DD/YYYY) Place of Birth
*Last SIX digits of Social Security Number (SSN)?
No SSN
Gender Height (feet, inches) Eye Color Race
M
F
Driver’s License of ID Number State of Issue
Father’s Full Name Mother’s Full Name
Current Address
* Residential Address (Where you actually reside)
B. Notarization Section – this section must be completed by a notary public
Notary Public Signature __________________________________
Commonwealth of Massachusetts
County of _________________________
Commission Expires: ________________
Street
Apt. #
City
State
Zip
Code
-
"On this ____ day of _______________ , 20___, before me, the undersigned notary public, ________________________________
(name of applicant) personally appeared, proved to me through satisfactory evidence of identification, which were
_______________________, to be the person who signed the preceding or attached document in my presence and who swore or
affirmed to me that the contents of the document are truthful and accurate to the best of (his) (her) knowledge and belief.
Seal of Notary Public
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Application To Renew A School Bus Driver Certificate (Commonwealth of Massachusetts)

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Completed 26 July 2020

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