p.2 LIC100_0119
F. Voter Registration
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
No
• 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.
• If you answered “Yes,” complete question #2 and read the Affirmation Section below.
• Check “No” if you are currently registered to vote and do not want to change your voter registration.
2. Are you a citizen of the United States of America? ............................................................................................................................
Yes
No
NOTE: If you answered “no” to this question, 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).
Democratic
Republican
Libertarian
Green-Rainbow
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
I hereby swear (affirm) that I am the person named above, that the above information is true, that I AM A CITIZEN OF THE UNITED STATES, that I
am at least 16 years old and I understand that I must be 18 years old to be eligible to vote, that I am not a person under a guardianship which prohibits
my registering to vote, that I am not temporarily or permanently disqualified by law from voting because of corrupt practices in respect to elections, that
I am not currently incarcerated for a felony conviction, and that I consider this residence to be my home. Signed under the penalty of perjury.
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).
G. Mandatory Questions
1. In the past 10 years, have you held any class of license, in any other state, country or jurisdiction? .....................................................
Yes
No
If yes, where? (Country/State) _______________________________ What credential class? _______________ What credential #? ____________
List any current license/permit also: _________________________________________________________________________________________
You may use additional paper if necessary.
2. Do you have a cognitive, neurologic, physical or any other impairment that may affect.........................................................................
Yes
No
your functional ability to operate a motor vehicle safely?
3. Are you currently taking any medication that may affect your ability to safely operate a motor vehicle? ...............................................
Yes
No
4. Is your license or RIGHT to operate suspended, revoked, canceled, withdrawn, or disqualified here or................................................
Yes
No
in another state, country or jurisdiction?
H. Parent/Guardian Consent for Applicants under the age of 18
(Information & Certification of Person Providing Consent)
If the person giving consent IS NOT a parent, proper documentation of authority must be shown.
I hereby certify I am: (check one) parent legal guardian Department of Children and Families 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 a Learner’s Permit or Driver’s License
OR who is less than 18 years of age, but not less than 14 years of age, if applying for an ID card, 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 24B).
Parent/Guardian’s Address: _________________________________________________________________________________________________
Parent/Guardian’s Signature:_____________________________________________________________
I. Certification and Signature of Applicant (application not complete without signature)
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 correct.
I am aware that false statements are punishable by fine, imprisonment, or both under M.G.L. Chapter 90, Section 24B.
Signature: __________________________________________________________ Date: __________________________
The Registrar reserves the right to cancel, revoke, or recall, any learner’s
permit, driver’s license, or ID card if it is determined that the applicant was
not qualified for such learner’s permit, driver’s license, or ID card.
RMV Use Only
Date: ___________________________ Clerk Initials: __________________
