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 send your Driver's License and future notices from the RMV)
U.S. Post Office MAY NOT deliver if your name is NOT on the mailbox.

926 Main ST Room 702
Residential Address (Where you actually reside)
! Same as above

Worcester / MA
City/State

01610
Zip Code

926 Main ST Room 702

Worcester / MA

01610

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. 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