Fillable VSC101 - Application For School Pupil Transportation 7D Certificate 0619 Fillable (Commonwealth of Massachusetts)

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VSC101 - Application For School Pupil Transportation 7D Certificate 0619 Fillable (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Application for a School Pupil Transportation (7D)
Certificate – New or Renewal
Save time, go to Mass.gov/RMV/7D to apply online!
Registry of Motor Vehicles ● Vehicle Safety & Compliance Services
P.O. Box 55892 ● Boston MA 02205-5892
p.1 VSC101_0619
IMPORTANT: This application must be completed, signed, and dated. Incomplete applications will be returned.
A. Checklist
Resident 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.
NEW training requirements:
Two hours of pre-service training for first time applicants (effective October 1, 2018).
Eight hours of in-service training for renewal applicants (effective October 1, 2019).
All pre-service and in-service training must be completed before submitting the application.
For a list of training sessions, go to Mass.gov/RMV/7D.
Fees: $15.00 for one-year certificate; $7.50 for six-month certificate.
Enclose check or money order payable to MassDOT.
Only original forms are accepted (no copies).
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 your application.
For 6-month applicants age 70 and older, CORIs run once a year.
Medical Requirements:
Applicant’s medical exam must be conducted and dated within the preceding 90 days of application submission. See section G – Patient
Information.
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: 7D
P.O. Box 55892
Boston, MA 02205-5892
An incomplete application will be returned. Save a copy of all submitted forms.
For questions, email SchoolBus7DNotify@state.ma.us or call Vehicle Safety and Compliance Services at 857-368-7310. For more information,
go to Mass.gov/RMV/7D.
B. Certificate Type
New
6-Month - $7.50 – (Over 70 years of age and insulin-dependent, diabetic, or have had a hypoglycemic episode.)
Renew
One -year - $15
C. Applicant Information
Last Name First Name Middle Name Suffix
Date of Birth (MM/DD/YYYY) Driver’s License # Social Security Number
License Class State of Issuance
Expiration (MM/DD/YYYY)
p.2 VSC101_0619
Residential Address (Where you actually reside)
Street Apt. #
City State
Zip
Code
Mailing Address
(same as above)
Street Apt. #
City
State
Zip
Code
Email Phone Type Phone #
Cell
Home
Work
Employer Information
Employer Name Address
Street City State
Zip
Code
Employer Email Phone Type Phone #
Cell
Home
Work
D. Pre-Service Training Requirement (new applicants)
An applicant for a school pupil transport operator shall complete a minimum of two hours of pre-service training as established and approved by the
Registrar prior to receiving the certificate. FOR SCHOOL PUPIL TRANSPORT CERTIFICATION, a trainer or designated person must sign below in
accordance with the requirements of 540 CMR 8.04(1).
Trainer or Designated Person Trainer’s License #
Email Address Phone #
Signature of Trainer or
Designated Person:
Total Driver Pre-Service Training Hours
E. In-Service Training Requirement (existing applicants)
An applicant to renew a school pupil transport certificate shall complete a minimum of eight hours of in-service training as established and approve by
the Registrar prior to receiving the certificate. FOR SCHOOL PUPIL TRANSPORT CERTIFICATION, a trainer or designated person must sign
below in accordance with the requirements of 540 CMR 8.04(2).
Trainer or Designated Person Trainer’s License #
Email Address Phone #
Signature of Trainer or
Designated Person:
Total Driver In-Service Training Hours
F. Certification and Applicant Signature
I have reviewed this completed Application 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.
Applicant’s Signature: ___________________________________________ Date: _________________________
G. Medical Information and Applicant Signature
I hereby authorize the Licensed Physician (M.D. or D.O.) completing this form to discuss and release any or all medical records pertaining to its
content with or to representatives of the Registry of Motor Vehicles.
Applicant’s Signature ___________________________________________________________ Date _________________________
p.3 VSC101_0619
H. Patient Information – Must be completed by a Licensed Physician, NOT a Nurse Practitioner, Physician Assistant, or
chiropractor.
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
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.
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/ ____________
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
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 pupil transport vehicle and fulfill all of the
duties and responsibilities associated with such operation.
The patient named above IS NOT medically qualified to operate a school pupil transport vehicle.
Additional Comments:
p.4 VSC101_0619
I. Physician Information and Attestation (M.D. or D.O only)
Massachusetts NPI #
Last Name First Name Middle Name
Phone # Address
Street
City/
Town
Zip
Code
Email
I hereby certify that the information provided herein is true, accurate and complete:
Physician’s Signature _________________________________________________________ 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.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 or 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
"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
Notary Public Signature __________________________________
Commonwealth of Massachusetts
County of _________________________
Commission Expires: ________________
Ft. In.
Street
Apt. #
City
State
Zip
Code
-
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VSC101 - Application For School Pupil Transportation 7D Certificate 0619 Fillable (Commonwealth of Massachusetts)

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Completed 27 July 2020

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