Class D or M Road Test Application

GENERAL INFORMATION Please fill out form clearly in blue or black ink Note: Applicants under the age of 18 who wish to obtain a Class
M (motorcycle) license or endorsement must complete the
MA Assigned License/ID/Permit License Class
Massachusetts Rider Education Program (MREP) and may not
S 1 0 6 6 1 0 9 2 D M book a road test with the RMV. For additional information, please
refer to the MassDOT RMV Division’s website at www.massrmv.
Last Name First Name Middle Name Date of Birth Sex Height
Month Day Year Feet Inches
Gaur Ashish 12 4 1982 M F 5 10
Mailing Address (Where you want us to send your Driver’s License and future notices from the RMV) City/State Zip Code
U.S. Post Office MAY NOT deliver if your name is NOT on the mailbox.
6 INDEPENDENCE WAY APT 401 FRANKLIN / MA 02038
Residential Address (Where you actually reside) Same as above City/State Zip Code
6 INDEPENDENCE WAY APT 401 FRANKLIN / MA 02038
PARENTAL CONSENT FOR MINOR; Information & Certification of Person Providing Consent
This section must be completed by a parent of the applicant, the legal guardian, the Massachusetts Child Guardian Division, or the Headmaster of
the Boarding School the applicant is attending. If the person giving consent IS NOT a parent, proper documentation of authority must be shown.
To the Registrar: I hereby certify I am: (check one) parent legal guardian Massachusetts Child Guardian Division 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).
• The applicant has completed the additional 40 hours of required supervised driving. Parent/Guardian Signature

• 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. Parent/Guardian Signature
False certification is punishable by fine, imprisonment, or both (M.G.L. Chap. 90, Section 24).

Parent/Guardian Address

Parent/Guardian Signature Printed Name

REQUIRED INFORMATION
1. Yes No Do you have a cognitive, neurologic, physical, or any other 2. Yes No Are you currently taking any medication that may
impairment that may affect your functional ability to operate a affect your ability to safely operate a motor vehicle?
motor vehicle safely?
(The Commonwealth’s medical standards for safe operation of a motor vehicle are Note: If you answered yes to questions 1 or 2, RMV Road Test
found at http://www.massrmv.com/medicalaffairs.aspx.) Staff must contact Medical Affairs.

SIGNATURE OF APPLICANT (application not complete without signature)

Note: This application will be processed through the National Driver Register (NDR) and the Commercial Driver License Information System (CDLIS) to verify the status of
operating privileges in other jurisdictions and the social security number will be verified with the Social Security Administration.
I have reviewed this completed Application Form and swear (affirm), under the penalties of perjury, that the information I have provided is true and complete. False
statements are punishable by fine, imprisonment, or both (M.G.L. c 90 §24).

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.
SPONSOR INFORMATION
For a Class D road test (including JOL) you must have a sponsor who fits the following criteria:
• Is at least 21 years old • Has had at least one year of driving experience
• Has a valid driver’s license issued by his or her home state (including District of Columbia). Holders of foreign driver’s licenses are not eligible to be sponsors.
Vehicle Used Registration Number State Sponsor License Number State

Sponsor Signature Date Examiner Name Examiner ID Location

TEST RESULTS - To be completed by examiner

Date Examined Please Check One Examiner Signature

PASS FAIL REJECT

REASON FOR FAILURE OR REJECTION Batch Number

9011003HJP89
T21844_0417
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PRE-STAGE Transaction Summary

Thank you for completing the online Pre-Staging application.

You must complete the following before your visit to the Registry:
1. Read all information in this document.
2. Review and sign your printed application form.
3. Bring all required documents including this page.
Application Information:
Name: Ashish Gaur
Date of Birth: Dec 04, 1982
Address: 6 INDEPENDENCE WAY APT 401
FRANKLIN, MA 02038
Application Type: Class D Road Test
Transaction ID number: 6JTFW
Required Documents:
o
Completed Class D Road Test application
o
Transaction Summary
o
Class D Permit.
o
All documents must be originals unless otherwise indicated. Photocopies will not be accepted.
Required Tests:
o
Class D Road Test
Fees: Please note that all fees are subject to change at any time.
Class D Road Test : $85

A $35 road test fee applies each time you take the road test in addition to a one-time license issuance fee. You
will see the complete breakdown of the transaction fees you owe when you are given the option to pre-pay after
you book a road test appointment.
Registry of Motor Vehicles Branch Visit
You are eligible to schedule a road test between Mar 06, 2018 and May 03, 2018. You can also save yourself a
trip to the branch by pre-paying your transaction fees after you schedule your appointment or at a later date by
visiting RMV Online Branch and selecting the Pay My Road Test and/or License Fees transaction from the
OnlineBranch page.
 PASSENGER VEHICLE (CLASS D) AND MOTORCYCLE (CLASS M)
ROAD TEST CHECKLIST

Do YOU have everything you need for your Road Test?

A completed Class D or M Road Test Application

• If you are under 18 years of age:
• Class D: The application must be signed by either: (a) a parent, (b) a legal guardian, (c) the Massachusetts Child
Guardian Division, or (d) a boarding school headmaster. If the person signing the application is not a parent,
proper documentation must be shown at the time of the road test to prove that the person is qualified to sign
• Class M: You must successfully complete a Massachusetts Rider Education Program (MREP) basic rider course
to obtain a Class M license

A valid learner’s permit

A sponsor
• Your sponsor must: (a) be 21 years of age or older; (b) have at least one year of driving experience; and (c) be duly licensed
by his/her state of residence
• Class M road tests do not require a sponsor

The sponsor’s valid driver’s license available for the Road Test Examiner to review

Does YOUR VEHICLE have everything it needs to be approved for use on your Road Test?

A valid vehicle registration

A valid inspection sticker

Seating accommodations for the driver and adequate seating so that the examiner may sit next to you and your sponsor may sit in
the rear seat behind the driver

Proof of insurance coverage equal to or exceeding the Massachusetts minimum requirements, which are $20,000/$40,000 for
bodily injury and $5,000 for property damage

A parking brake within reach of the front passenger seat

Please Note: Any vehicle that does not allow the examiner unobstructed access to the parking brake cannot be
used

For Rental Vehicles: Your rental agreement and written permission on the rental company’s letterhead
authorizing use of the vehicle for the road test is required