Nonresident Student Driver Form

NOTE: To complete this form, you must have the REFERENCE NUMBER provided by the Gordon Police in the email you received after submitting your online vehicle registration form. Contact us (email below) if you need us to re-send that reference number.

Per Commonwealth of Massachusetts law, every nonresident college student who operates a motor vehicle in Massachusetts that is registered in another state, must complete this form and display a nonresident student decal on his/her vehicle.

This form must be filled out completely and accurately; all fields are required. If you choose not to submit the form, please be aware that you may be cited by any police officer in the Commonwealth (the fine is $200). There is no charge for the nonresident student decal, which will be provided by the Gordon Police upon receipt of this form.

IMPORTANT NOTE:
MA requires that we provide you with the following written warning:
Pursuant to the provisions of M.G.L c.90 § 3, as amended by Chapter 46 of the Acts of 2003, this form must be completed in quadruplicate by every nonresident enrolled as a student at a public or private school or college in the Commonwealth during any period beginning on September 1st of any year and ending on August 31st of the following year, who operates a motor vehicle in Massachusetts that is registered in another state or country. This applies to students commuting from out-of-state to a school in Massachusetts and students temporarily residing in Massachusetts, whether living on campus or not. This completed form must be filed with the Police department in the city or town where the school is located. The Police department must provide a copy to the school, the local assessor, and the RMV. The school will issue the required decal, which must be affixed to the uppermost center portion of the windshield. The penalty for a nonresident’s failure to comply as required is up to $200.00.

We recommend that you have your vehicle registration and proof of insurance handy before attempting to complete this form. Most of the information requested will be found on those documents.

If you have any questions, please don't hesitate to contact us at [email protected].

1. REFERENCE NUMBER: Provided by Gordon Police in the email you received after submitting your online vehicle registration form. Contact us if you need us to re-send the reference number.

2. LAST NAME: The STUDENT'S last name.

3. FIRST NAME: The STUDENT'S first name.

4. MIDDLE INITIAL: The STUDENT'S middle initial.

5. PHONE NUMBER: The STUDENT'S phone number.

6. EMAIL ADDRESS: The STUDENT'S email address.

7. PERMANENT ADDRESS — STREET: The STUDENT'S permanent (home) street address (house number and street).

8. PERMANENT ADDRESS — CITY: The STUDENT'S permanent (home) city.

9. PERMANENT ADDRESS — STATE: The STUDENT'S permanent (home) state.

10. PERMANENT ADDRESS — ZIP CODE: The STUDENT'S permanent (home) zip code.

11. PERMANENT ADDRESS — COUNTRY: The STUDENT'S permanent (home) country.

12. LOCAL RESIDENTIAL ADDRESS — STREET: The STUDENT'S local address (if you live on campus, this is 255 Grapevine Road; if you are a commuter, provide your local commuter address).

13. LOCAL RESIDENTIAL ADDRESS — CITY: The STUDENT'S local address (if you live on campus, this is Wenham).

14. LOCAL RESIDENTIAL ADDRESS — STATE: The STUDENT'S local state (if you live on campus, this is MA).

15. LOCAL RESIDENTIAL ADDRESS — ZIP CODE: The STUDENT'S local zip code (if you live on campus, this is 01984).

16. VEHICLE PLATE# (also known as Registration Number): Your vehicle plate, as written on your registration document.

17. VEHICLE REGISTRATION STATE: The state that issued your vehicle plate.

18. REGISTRATION EXPIRATION DATE: From your registration document, the date your vehicle registration expires (MM/DD/YYYY).

19. VEHICLE MAKE: Examples: Ford, Toyota, etc.

20. VEHICLE MODEL: Examples: Taurus, Corolla, etc.

21. VEHICLE COLOR: From your registration document, your vehicle's color.

22. VEHICLE YEAR:

23. VEHICLE VIN#: From your registration document, the Vehicle Information Number (VIN) of your vehicle.

24. VEHICLE OWNER'S LAST NAME: From your registration document, the last name of the registered owner.

25. VEHICLE OWNER'S FIRST NAME: From your registration document, the first name of the registered owner.

26. VEHICLE OWNER'S MIDDLE INITIAL: From your registration document, the middle initial of the registered owner.

27. VEHICLE OWNER'S ADDRESS — STREET: From your registration document, the street address of the registered owner.

28. VEHICLE OWNER'S ADDRESS — CITY: From your registration document, the city of the registered owner.

29. VEHICLE OWNER'S ADDRESS — STATE: From your registration document, the state address of the registered owner.

30. NAME OF INSURANCE COMPANY:

31. INSURANCE COMPANY MAILING ADDRESS: This should be located on your proof of insurance document.

32. EXPIRATION DATE OF INSURANCE POLICY (MM/DD/YYYY):

33. Minimum Mandatory Insurance Coverage Question #1: Per MA law (M.G.L., c. 90, Sec 3), this vehicle can only be operated during such time as the owner thereof maintains in full force a policy with coverage sufficient to allow a “Yes” to this question:

Does this policy provide at least $20,000 coverage for injury or death to one person and $40,000 coverage for injury or death to more than one person while the vehicle is being operated on the ways of Massachusetts?

YES (Note: the answer must be YES to operate this vehicle in MA.)

34. Minimum Mandatory Insurance Coverage Question #2: Per MA law (M.G.L., c. 90, Sec 3), this vehicle can only be operated during such time as the owner thereof maintains in full force a policy with coverage sufficient to allow a “Yes” to this question:

Does this policy provide indemnity for any operator of this vehicle while being operated with the express or implied consent of the owner?

YES (Note: the answer must be YES to operate this vehicle in MA.)

35. AFFIRMATION OF WRITTEN WARNING: Per MA law, the college must provide you with the following written warning:

"IT IS UNLAWFUL FOR A NONRESIDENT STUDENT TO FAIL TO FILE A NONRESIDENT DRIVER STATEMENT WITH THE POLICE DEPARTMENT LOCATED IN THE SAME CITY OR TOWN AS THE SCHOOL OR COLLEGE ATTENDED, IN ACCORDANCE WITH SECTION 3 OF CHAPTER 90 OF THE MASSACHUSETTS GENERAL LAWS. FAILURE TO FILE SUCH STATEMENT IS PUNISHABLE BY A FINE NOT TO EXCEED $200.”

Please select YES to affirm that you have been provided with this written warning.

YES

36. ELECTRONIC SIGNATURE (FULL NAME): By entering your full name below, you are providing your electronic signature and affirming the following:

I 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. I also understand that a copy of this filing will be provided to the local assessor where I reside.

37. DATE SIGNED: Please enter the date (today's date in MM/DD/YYYY format) that you entered your electronic signature.