Non-Massachusetts Registration Form

Nonresident Driver Registration
Nonresident Student Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
College Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vehicle Information
Registration Number*
State, Province, and Country of Registration*
Registration Exp. Date*
Year*
Make*
Model*
Color*
Vehicle Identification Number*
Vehicle Owner's Name*

First NameLast Name
Vehicle Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Liability Insurance Information

This vehicle can only be operated during such time as the owner thereof maintains in full force a policy covering all of the provisions in M.G.L., Ch. 90, Sec3. Coverage sufficient to allow a "yes" to both a) and b) is required.
Does this policy include or have 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?*

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

YesNo
Name of insurance Company & Address:*
Expiration Date of Policy:*
Did you receive a written warning from your school indicating a penalty of up to $200.00 for your failure to file the completed nonresident driver statement with the policy department?*

YesNo
Sign the form by providing your full name:*
Should be Empty:

Nonresident Driver Registration

Nonresident Student Information

Vehicle Information

Liability Insurance Information