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Road Test Essay

1737 words - 7 pages

Class D or M Road Test Application
GENERAL INFORMATION
MA Assigned License/ID/Permit Number License Class

S

8

6

2

7

3

4

4

5
First Name

#D

#M
Middle Name

Note: Applicants under the age of 18 who wish to obtain a class M (motorcycle) license or endorsement must complete the Massachusetts Rider Education Program (MREP) and may not book a road test with the RMV. For additional information, please refer to the MassDOT RMV Division's website at mass.gov/rmv.
Month

Last Name

Date of Birth

Zhang

Qing

Day

Year

Sex

9
City/State

2

1990

#M #F 6
Zip Code

Feet

Height

Inches

7

Mailing Address (Where you want us to ...view middle of the document...

(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 If the person giving consent IS NOT a parent, proper documentation of authority must be shown. 2. !Yes !No Are you currently taking any medication that may affect your ability to safely operate a motor vehicle? Note: If you answered yes to questions 1, or 2 an RMV Branch Representative must contact the Medical Affairs Branch(MAB).

REQUIRED INFORMATION
1. !Yes !No Do you have any medical condition that may affect your ability to safely operate a motor vehicle?
(The RMV’s Medical Advisory Board has established standards to determine fitness to operate a motor vehicle. Ask an RMV Branch Representative for a summary of these standards or visit our website at www.mass.gov/rmv for the complete list of these standards.)

) 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 Sponsor Signature Registration Number Date State Sponsor License Number State

Examiner Name

Examiner ID

Location

TEST RESULTS - To be completed by examiner
Date Examined

# PASS # FAIL # REJECT
Batch Number

Please Check One

Examiner Signature

REASON FOR FAILURE OR REJECTION

9011000N37HQ
...

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