Form Dl-180 - Non-Commercial Learner'S Permit Application Page 2
Download a blank fillable Form Dl-180 - Non-Commercial Learner'S Permit Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dl-180 - Non-Commercial Learner'S Permit Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2DL-180 (8-15)
MUST
all information in this section
be completed in full by a health care provider
Please check any of the following that would prevent control of a motor vehicle.
Neurological disorders
Neuropsychiatric disorders
Circulatory disorder
Cardiac disorder
Hypertension
Uncontrolled Epilepsy
Uncontrolled Diabetes
Cognitive Impairment
Alcohol abuse
Drug abuse
Conditions causing repeated lapses of consciousness (e.g. epilepsy, narcolepsy, hysteria, etc.)
Specify: _____________________________________________ If seizure disorder, date of last seizure: ________________________
Impairment or Amputation of an appendage. If so, list: _________________________________________________________________
Other: _______________________________________________________________________________________________________
NOTE: Any recommendations/additional comments must accompany this certificate on a health care provider's letterhead.
PROVIDER INFORMATION (Please print or type)
PROVIDER'S NAME
SPECIALTY
STATE LICENSE #
STREET ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE
FAX
I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements made
herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities) punishable by a fine up to $2,500
and/or imprisonment up to 1 year.
Examinee's Signature (SIGN ONLY IN PRESENCE OF PROVIDER)
Provider's Signature
Physical Date
must
:
to meet identification requirements you
present the following
u.s. Citizens
Non-U.S. Citizens – You must bring ALL of the following:
-
Social Security Card (must be original; card cannot be laminated)
• Social Security Card (must be original; card cannot be laminated)
AND ONE of the following:
• Valid Passport
• Birth Certificate with raised seal
( U.S. issued by an authorized
• All original USCIS/immigration documents
government agency, including U.S. territories or Puerto Rico.) No
(Student Status Only)
• Written verification of attendance from school
other birth documents will be accepted.
(Employment Status Only)
• Written verification from employer
• Certificate of U.S. Citizenship
(BCIS/INS Form N-560)
To obtain detailed information regarding "identity/residency
(BCIS/INS Form N-550 or N-570)
• Certificate of Naturalization
requirements," you can:
• Valid U.S. Passport (Only valid U.S. Passports and original
• Visit the Identity/Security Info Center at
documents will be accepted.)
• Call us at 1-800-932-4600 or 1-800-228-0676 (TDD)
NOTE:
If you have an Out-of-State Driver's License, you should
Monday through Friday from 8 a.m. to 5 p.m., or
present it along with your Social Security Card and one of the
• Visit one of our Driver License Centers.
above forms.
All documents must show the same name and date of birth, or an association between the information on the documents.
Additional documentation may be required, if a connection between documents cannot be established (e.g. Marriage
Certificate, Court Order of name change, Divorce Decree, etc.)
must
:
(for customers 18 years of age or older)
to meet residency requirements you
present two of the following
• Tax Records • Lease Agreements • Mortgage Documents • W-2 Form • Current Weapons Permit (U.S. Citizen only)
• Current Utility Bills (water, gas, electric, cable, etc.)
--The proof of residency documents must have your name and official Pennsylvania street address on it.--
Note: If you reside with someone, and have no bills in your name, you will still need to provide two proofs of residency. One proof is to bring the person with
whom you reside along with their Driver's License or Photo ID to the Driver License Center. You will also need to provide a second proof of residency such as
official mail (bank statement, tax notice, magazine etc.) that has your name and physical address on it. The address must match that of the person with whom
you reside.
Veterans Designation: You have the opportunity to add the veterans designation to your driver's license, which clearly indicates you are a veteran of the
United States Armed Forces. To qualify, you must have served in the United States Armed Forces, including a reserve component or the National Guard, and
have been discharged or released from such service under conditions other than dishonorable. If you are requesting to add the veterans designation to your
license, make sure you check the box at the top of the Authorization and Certification Section on side 1.
ORGAN DONATION AWARENESS TRUST FUND (ODTF): You have the opportunity to contribute $1.00 to the Fund. The
additional $1.00 contribution must be added to your payment. You must also check the block provided to ensure proper handling
of your contribution. The ODTF provides for the development and implementation of donor awareness programs and funds shall be
appropriated subject to the approval of the Governor.
VETERANS' TRUST FUND (VTF): You have the opportunity to make a tax deductible contribution to the VTF. Your contribution will help support
programs and projects for Pennsylvania veterans and their families. Since this additional $3.00 is not part of the fee, please add the donated amount
to your payment. Also, please check the proper block on the form to ensure your contribution is handled properly.
Permit Fee: Additional permit fee of $5.00 for each permit requested.
MSEA Fee: These additional fees are required under the Pennsylvania Vehicle Code Section 7904 and will be used to support a
Motorcycle Safety Education Program in the Commonwealth of Pennsylvania.
PROVISIONS OF SECTION 3709 OF THE VEHICLE CODE
Section 3709 provides for a fine of up to $300 for dropping, throwing or depositing, upon any highway, or upon any other public or private
property without the consent of the owner thereof or into or on the waters of this Commonwealth, from a vehicle, any waste paper, sweepings,
ashes, household waste, glass, metal, refuse or rubbish or any dangerous or detrimental substance, or permitting any of the preceding without
immediately removing such items or causing their removal.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dl-31 - Non-commercial Learner's Permit - Application To Add/extend/replace/change/correct - Pennsylvania Department Of Transportation
Legal
Form Dl-901 - Non-commercial Driver's License / Identification Card / Learner's Permit Application To Renew / Replace / Change / Correct
Legal
Related Categories
Parent category: Legal