p.2 LIC104_0119
E. Mandatory Questions (Use additional paper if needed for these questions)
1.
Yes
No
In the past 10 years, have you held any class of driver’s
license in another state, country, or jurisdiction? List any
current license/permit also.
If yes, where? Class of License License #
____________________ ____________ ________________________
____________________ ____________ ________________________
You may use additional paper if necessary
2.
Yes
No
Do you have a cognitive, neurologic, physical, or any other
impairment that may affect your functional ability to
operate a motor vehicle safely? (for information on medical
standards related to driver’s licenses, visit mass.gov/rmv)
3.
Yes
No
Are you currently taking any medication that may affect
your ability to safely operate a motor vehicle? (for
information on medical standards related to driver’s licenses,
visit mass.gov/rmv)
4.
Yes
No
Are you subject to any driver disqualification under 49
CFR Section 383.51 of the Federal Motor Carrier Safety
Regulations and MGL Chapter 90F Section 9?
5.
Yes
No
Is your license or RIGHT to operate suspended,
revoked, canceled, withdrawn, or disqualified here or
in another state, country, or jurisdiction?
If yes, where? ________________________________________________
Why? ______________________________ Exp.Date: _______________
(Note: If you answered yes, additional documentation may be required)
6.
Yes
No
Do you meet all the driver qualification requirements of
the Federal Motor Carrier Safety Regulations, 49 CFR
Part 391?
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. 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 Commercial Driver’s License
(CDL) or Commercial Learner’s Permit (CLP) and swear (affirm), under the penalties of perjury, that the information I have provided is true and
correct. I understand that Federal law requires the Registrar to check my driving records in all jurisdictions where I have been licensed in the past 10
years and to respond to similar requests from other states and Canadian territories and provinces, from employers or prospective employers, and from
insurers, as applicable and that other requests may be governed by the federal Driver Privacy Protection Act. I consent to the release of these records.
I certify that I am a U.S citizen or have lawful permanent residency within the United States.
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 permit,
license, or ID card if it is determined that the applicant was not qualified
for such permit, license, or ID card.
Important Note: CDL drivers and applicants must self-certify and
provide a copy of their U.S. DOT Medical Certificate if required.
RMV Use Only
Date: ________________________ Clerk Initials: ___________
