Form Dl-180 - Non-Commercial Learner'S Permit Application

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DL-180 (8-15)

NON-COMMERCIAL LEARNER'S PERMIT APPLICATION

YOU MUST APPLY IN PERSON

DRIVER'S LICENSE

THIS FORM IS VALID FOR 1 YEAR FROM THE DATE OF PHYSICAL EXAMINATION

The physical date may not be more than 6 months prior to your 16th birthday.

NUMBER/I.D. NUMBER:

JR./ETC

LAST NAME (S)

FIRST NAME

MIDDLE NAME

DATE OF BIRTH

HEIGHT

SOCIAL SECURITY NUMBER

SEX

TELEPHONE NUMBER (

)

8:00A.M. - 4:30P.M.

MONTH

DAY

YEAR

FEET

INCHES

EYE COLOR

BLUE

BROWN

GREEN

HAZEL

PINK

BLACK

GRAY

DICHROMATIC

OTHER ________________

(Please check one):

STREET ADDRESS - A Post Office Box number may be used in addition to the actual residence

CITY

STATE

ZIP CODE

address, but cannot be used as the only address.

enter fee

PERMIT(S) DESIRED

FEE

for each

CHECK

item checked

DESIRED

$5.00

PERMIT(S)

CLASS A (Combination Vehicle over 26,000), CLASS B (Truck or Bus over 26,000) OR CLASS C (Automobile)

$15.00

CLASS M (Motorcycle) MSEA Fee is included

LICENSE REQUIRED

FEE

enter fee for

MUST

license checked

CHECK

4-Year Photo

$29.50

ONE

2-Year Photo (Age 65 & Over)

$19.00

ENTER FEE FOR

Trust Fund Contribution(s) - If you wish to contribute to the Organ Donation Awareness Trust Fund (ODTF) and/or the Veterans' Trust Fund (VTF)

CONTRIBUTION(S) HERE

check the appropriate box(s) and enter total amount to the right. (see reverse)

$1.00 to the Organ Donation Trust Fund (ODTF)

$3.00 to the Veterans' Trust Fund (VTF)

TOTAL

PAID BY:

Check

Money Order

Payable to PennDOT (Cash CANNOT be accepted)

ALL QUESTIONS MUST BE ANSWERED

(Check [4] Applicable Block)

YES NO

1. Have you ever held or possessed a PA Driver's License/Learner's Permit/Photo Identification Card?..........................................................

2. Is your right to apply for a license or your privilege to operate a vehicle in this or any other state currently

suspended, revoked, or subject to installation of an ignition interlock device? .............................................................................................

If yes, give state

date

, and reason

3. Do you have any pending criminal charges or driving violations in this state or any other state which may carry a possible

penalty of suspension or revocation of your driver's license or driving privilege?........................................................................................

If yes, give state

date

, and reason

4. Do you hold a valid license or ID card from any other state? ..........................................................................................................

AUTHORIZATION AND CERTIFICATION

Veterans Designation: I certify under penalty of law that I am a qualified applicant and hereby request it be added to my product. I understand that misrepresentation will result

in the cancellation of my driver's license.

I certify under penalty of law that this information contained herein is true and correct. I hereby authorize the Social Security Administration to release to the Department of Transportation

information concerning my Social Security Identification Number for the purpose of identification. I hereby acknowledge this day that I have received notice of the provisions of Section

3709 of the Vehicle Code. (See back for provisions)

WARNING: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500 and/or imprisonment up to 1 year (18 Pa. C.S. Section 4904[b]).

I am under the age of 18 years and I hereby request Organ Donor designation on my PA Driver’s License. Parent must check consent block on the

ParenGuardian Consent Form (DL-180TD). (Applicants 18 years of age or older will have the opportunity to request Organ Donor designation at

the Photo Center at the time they have their photo taken.)

I hereby certify that I am a resident of the Commonwealth of Pennsylvania.

SIGN

HERE

(APPLICANT'S SIGNATURE IN INK)

(DATE)

FOR OFFICIAL USE ONLY

COMPLETED BY DRIVER LICENSE EXAMINER OR A PROVIDER

COMPLETED BY DRIVER LICENSE EXAMINER ONLY

YES NO