Fillable Registry of Motor Vehicles - CDL Road Test Application RDT104

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Registry of Motor Vehicles - CDL Road Test Application RDT104

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Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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CDL Road Test Application
Save time, go to mass.gov/RMV to apply online!
p.1 Please complete reverse side RDT104_0319
A. Applicant Information
Last Name First Name Middle Name Suffix
Date of Birth (MM/DD/YYYY) Current Massachusetts Learner’s Permit or Driver’s License # (if applicable) What is your Social Security Number?
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:
A
B
C
CDL endorsements applying for:
Air Brakes
Combo
Passenger
School Bus
Motor Bus
C. 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revoked, canceled, withdrawn, or disqualified here or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?
D. Sponsor Information
Please be aware that as a sponsor you are subject to Chapter 90 Section 8B, which states in part:
“Such licensed operator shall be liable for the violation of any provision of this chapter, or of any regulation made in accordance herewith, committed
by such persons with a learner’s permit; provided, however, that an examiner in the employ of the Registrar, when engaged in his official duty, shall
not be liable for the acts of any person who is being examined by said examiner.”
Sponsors must also meet the following requirements:
1. Be at least 21 years old.
2. Have a valid U.S. Commercial Driver’s License with proper endorsements for the class of vehicle that you are using.
3. Have a current DOT medical card. (If the sponsor does not have a current DOT medical card, he/she will be subject to a fine.*
The test, however, will still proceed.)
*A DOT medical card is not required for a state or municipal employee using a state or municipal vehicle.
Sponsor License Number Expiration (MM/ DD/ YYYY) Class State
Sponsor Printed Name Sponsor Signature Date (MM/DD/YYYY)
Bus Company (if applicable) Bus Company Contact Information (if applicable)
p.2 RDT104_0319
E. Vehicle Information
Vehicles used for a Class A, B, or C road test must meet the following requirements. Vehicles not meeting the following requirements will be
refused/rejected.
Represent the type and class of vehicle you will be driving when you
receive your CDL. For a Passenger Endorsement, the applicant must
have the appropriate class vehicle designed to carry 16 or more
passengers, including the driver.
Be able to pass a safety check. Vehicles with unstable, dangerous, or
HAZMAT loads will be rejected. The vehicle must be completely free
of hazardous material.
Have a valid registration and current inspection sticker.
Have adequate seating next to the operator for the use of the
examiner.
Have a manufacturer’s gross vehicle weight rating (GVWR) on the
vehicle, appropriate for the class of license for which you are applying.
If there is no GVWR on the vehicle, you must have a document from
the manufacturer or a motor vehicle dealer proving the GVWR.
Out-of-State Registered Vehicles, Trailers, and Semi Trailers
Carry proof of insurance coverage in the form of a policy or letter from the insurance company specifying the limits of coverage. The insurance
coverage MUST be equal to Massachusetts minimum requirements of $20,000/$40,000P bodily injury and $5,000 property damage coverage for
the vehicle’s use in Massachusetts. (No faxes or photo copies.)
Rental Vehicles
Have the rental agreement and written permission on the rental company’s letterhead authorizing use of the vehicle for the road test.
Vehicle Make/Year Tractor Registration Number/GVWR State Trailer Make/Year Trailer Registration Number/GVWR State
F. CDL Road Test Information To be completed by examiner
Parts of Test Pass Fail Reason for Failure or Rejection Comments
1. Pre-Trip Inspection .......................
2. Air Brakes .....................................
3. Straight Backing............................
4. Offset Backing Left or Right ..........
5. Parallel Park (Conventional) .........
6. Parallel Park (Sight Side) ..............
7. Alley Dock.....................................
8. Road Test .....................................
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Restriction Code Add Delete
_____________
_____________
_____________
_____________
Examiner Name Examiner ID # Date Examined (MM/DD/YYYY) Location
Examiner Signature ___________________________________________________________ Date ___________________
G. Applicant Requirements
Applicants must meet all of the following requirements for a Class A, B, or C road test in order to be tested:
Have a current driver’s license, if you are seeking additional endorsements.
Have a valid CDL permit, with proper endorsements for the vehicle used.
Have completed CDL self-certification and provided a valid U.S. Department of Transportation (DOT) medical card or medical waiver*
Have a completed road test application.
Be on time for the skills test. If you are late, you will not be examined. If you must cancel or reschedule your appointment with less than 72 hours’
notice, you will be responsible for the skills test fee.
H. 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 _________________________
MA Assigned CDL Permit/License Number
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.
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Registry of Motor Vehicles - CDL Road Test Application RDT104

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Completed 10 May 2020

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