Class D or M Road Test Application
Save time, go to mass.gov/RMV to apply online!
p.1 RDT103_0218
Date of Birth (MM/DD/YYYY)
Current Massachusetts Learner’s Permit or Driver’s License # (if applicable)
Residential Address (Where you actually reside)
Street Apt. # City State
Zip Code
Mailing Address
(same as above)
Street
Apt. # City State Zip Code
B. Service Type ‒ License Class:
D
M
C. Parent/Guardian Consent for Applicants under the age of 18:
Information and 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 1/2 years of age, and that my consent is given as required by
M.G.L. Chap. 90, Section 8 for the issuance of a Driver’s License. I further certify by my separate signature that the applicant has completed the
required number of hours of behind-the-wheel driving by a validly licensed person aged 21 or over, with at least one year of driving experience, in
addition to the requirements of the driver education and training program. (Sign the appropriate time period and sign again at the bottom where noted).
1. The applicant has completed the additional 40 hours of required
supervised driving. 1. Parent/Guardian Signature: __________________________________
2. Completion of Skills Program: The applicant has completed the
additional 30 hours of required supervised driving and successfully
completed an RMV approved driver skills development program. 2. Parent/Guardian Signature: __________________________________
False certification is punishable by fine, imprisonment, or both (M.G.L. Chap. 90, Section 24B).
Parent/Guardian Address: _________________________________________________________________________________________________
Parent/Guardian Signature: ____________________________________________ Printed Name: ________________________________________
(for information on medical standards related to driver’s licenses, visit mass.gov/rmv)
1.
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?
2.
Yes
No
Are you currently taking any medication that may affect
your ability to safely operate a motor vehicle?
Sponsor Signature: ____________________________________________________________ Date: _______________________
Test results to be completed by Examiner
Pass Fail Reject
Reason for Failure or Rejection
G. Certification and Signature of Applicant
(application not complete without signature)
I have reviewed this completed Application Form 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 permit, license, or ID card
if it is determined that the applicant was not qualified for such permit, license, or ID card.
