Driver’s License, Learner’s Permit

or ID Card Application
(Passenger (Class D), Motorcycle (Class M), Class D/M, or Massachusetts Identification Card)
Save time, go to mass.gov/RMV to apply online!
A. Service Type
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A1. Type: REAL ID  Standard ID A2. Document to Issue: Learner’s Permit ■
 Driver’s License  Massachusetts ID Card

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A3. Class of Learner’s Permit/License (if applicable): Passenger (Class D) Motorcycle (Class M) Both (Class D/M)

A4. Service Type: New Renewal Replacement Out-of-State Conversion Reinstatement CDL Downgrade
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 Change of Information (Enter new information in applicable fields): Name Address DOB Gender Height Eye Color

B. Applicant Information (The Registry of Motor Vehicles will not provide email or phone number information to the public.)
B1. Last Name (If you’re getting a REAL ID, provide your full legal name) B2. First Name B3. Middle Name B4. Suffix
Calderone Louis Hannah
B5. Current Massachusetts Learner’s Permit or Driver’s License # (if applicable) B6. Date of Birth (MM/DD/YYYY)
S 8 3 5 6 5 5 7 0 06/11/1995
B7. What is your Social Security Number (SSN)? B8. If you do not have an SSN, you will need an SSA Denial Notice and foreign passport for REAL IDs
or ID Cards. You may apply for a Standard Learner’s Permit or Driver’s License using an SSA Denial
Notice OR an Affidavit of No SSN with an unexpired foreign passport or consular ID.
Check below if providing a foreign passport or consular ID and write the number and country.
 Foreign Passport  Consular ID
0 3 0 7 8 5 6 7 4 Number Country of issuance
B9.  ■
Have you ever had a Massachusetts permit, license, ID, or vehicle registration? If yes, provide the name it was under and the # (if known).
Hannah Elizabeth Calderone S83565570 Registration # 997WN2
B10. Residential Address (Where you actually reside)
Street 29 Lori Lane Apt. # City East Longmeadow State MA Zip Code 01028
B11. Mailing Address  (same as above)
Street Apt. # City State Zip Code
B12. Email B13. Phone Type B14. Phone #
hancalderone@gmail.com ■ Cell  Home  Work 617-957-2477
Emergency Contact Information: (optional)
B15. Email B16. Name B17. Phone Type B18. Phone #
 Cell  Home  Work

C. Out of State Conversion (Only complete if you are from another state, a U.S. territory, or a country the RMV has a reciprocal
arrangement with – for a list of countries, see www.mass.gov/how-to/transfer-your-drivers-license-from-a-foreign-country)
C1. Driver’s License, Learner’s Permit or ID Card # C2. Document Type C3. Restriction(s) (if applicable)
 Learner’s Permit  Driver’s License  ID Card
C4. Country C5. State C6. Issue Date (MM/DD/YYYY) C7. Expiration Date (MM/DD/YYYY)

D. Required Demographic Information

D1. Gender D2. Eye Color D3. Height (feet, inches)

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 M F X ■
 Black Brown Gray Hazel Pink Blue Dichromatic Green Maroon Unknown 5'5
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D4. Register me (or keep me registered) as an Organ and Tissue Donor:  Yes  No For more information on organ and tissue donation, visit NEDS.org.

D5. Would you like to donate $2 to the Organ and Tissue Donor Registration Fund? (for renewal and replacement transactions only)  Yes No
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Military Status (documentation is required if checked – visit mass.gov/rmv for acceptable documents)

D6.  Are you an active duty member? D7.  If you are a veteran of the U.S. Armed Forces, D8. What military branch?
 Are you a veteran? do you want the word “VETERAN” printed on your ID?

E. CDL Downgrade (if applicable)

E1. CDL Downgrade: I understand that my CDL will be downgraded to a Class D,
M, or D/M license and I authorize the RMV to process this transaction.

Applicant Signature: ________________________________________________

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 F. Voter Registration
If your citizenship is confirmed, the information you provided will be transmitted to the appropriate election official in the municipality where
you reside and will be used to update your voter registration or register you to vote.

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F1. Are you a citizen of the United States?.................................................................................................................................................  Yes  No
To be eligible for voter registration, you must be:
 A U.S. citizen, and
 A Massachusetts resident, and
 At least 16 years old, and
 Not under guardianship that prohibits registering to vote, and
 Not temporarily or permanently disqualified by law from voting, and
 Not currently incarcerated for a felony conviction.
If you do not meet all of the above conditions, you will not be registered to vote.
If you are at least age 16 at the time of application, you will be pre-registered to vote. You will become registered and eligible to vote when you turn 18.
If you are under age 16, you will not be pre-registered.
The office at which you submit your registration is confidential and will only be used for voter registration purposes.

AFFIRMATION FOR APPLICANTS REGISTERING TO VOTE (signed under the penalty of perjury)
I hereby swear (affirm) that I am the person named above, the above information is true, and that I consider the residential address provided to be my
home. I understand that if I do not meet one or more of the above conditions, I must opt out of registering to vote when I receive the automatic voter
registration mailing.
Penalty for illegal voter registration: Fine of not more than $10,000 or imprisonment for not more than five years or both (M.G.L., Chap. 56, Section 8).

G. Mandatory Questions (Question 1 to be completed by all applicants; questions 2-4 to be completed by Permit/License
applicants only)
G1. In the past 10 years, have you held any class of license, in any other state, country or jurisdiction? ...................................................  Yes  No ■
If yes, where? (Country/State) _______________________________ What credential class? _______________ What credential #? ____________

List any current license/permit also: _________________________________________________________________________________________

You may use additional paper if necessary.
An out of state driver’s license or identification card is subject to cancellation upon issuance of a Massachusetts driver’s license or identification card.
G2. Do you have a cognitive, neurologic, physical or any other impairment that may affect .......................................................................  Yes  No
your functional ability to operate a motor vehicle safely?
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G3. Are you currently taking any medication that may affect your ability to safely operate a motor vehicle? .............................................  Yes ■
 No
G4. Is your license or RIGHT to operate suspended, revoked, canceled, withdrawn, or disqualified here or ..............................................
in another state, country or jurisdiction?
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 Yes  No

H. Parent/Guardian Consent for Applicants under the age of 18

(Information & Certification of Person Providing Consent)
If the person giving consent IS NOT a parent, proper documentation of authority must be shown.
H1. 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 years of age, if applying for a Learner’s Permit or Driver’s License
OR who is less than 18 years of age, but not less than 14 years of age, if applying for an ID card, and that my consent is given as required by M.G.L.
Chap. 90, Section 8 for the issuance of a Driver’s License; or as required by M.G.L. Chap. 90, Section 8B for a Learner’s Permit; or by M.G.L. Chap.
90, Section 8E for an Identification Card (ID). False certification is punishable by fine, imprisonment, or both (M.G.L. Chap. 90, Section 24B).

H2. Parent/Guardian’s Printed Name:

H3. Parent/Guardian’s Address: ______________________________________________________________________________________________

H4. Parent/Guardian’s Signature: _________________________________________________________

I. Certification and Signature of Applicant (application not complete without signature)

I have reviewed this completed Application Form, including the Voter Registration Section, and hereby apply for a Learner’s Permit/Driver’s License
or an ID card 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 learner’s
permit, driver’s license, or ID card if it is determined that the applicant was
not qualified for such learner’s permit, driver’s license, or ID card.
Official Notice:
Massachusetts law requires persons convicted as a sex offender to register
with their local police departments. For information, call 1-800-93MEGAN or
visit https://www.mass.gov/orgs/sex-offender-registry-board

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