Form Dl-31 - Non-Commercial Learner'S Permit - Application To Add/extend/replace/change/correct - Pennsylvania Department Of Transportation
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2DL-31 (12-16)
NON-COMMERCIAL LEARNER'S PERMIT
APPLICATION TO ADD/EXTEND/REPLACE/CHANGE/CORRECT
Bureau of Driver Licensing • P.O. Box 68272 • Harrisburg, PA 17106-8272
If you have not taken or successfully completed the Road Test within three (3) years of your physical examination date,
you MUST start over with another Non-Commercial Learner's Permit Application and retake the Knowledge Test.
NOTE: COMPLETE ALL INFORMATION AS IT APPEARS ON YOUR CURRENT PENNSYLVANIA NON-COMMERCIAL DRIVER'S LICENSE OR LEARNER'S PERMIT
A
DRIVER'S LICENSE NUMBER
LAST NAME
JR/ETC
FIRST NAME
MIDDLE NAME
DATE OF BIRTH
TELEPHONE NUMBER (8:00 A.M.-4:30 P.M.)
E-MAIL ADDRESS (if applicable)
Month
Day
Year
CHECK APPLICABLE BLOCK ON LINE 1 AND LINE 2:
1.
ADD/EXTEND
LOST (Replace)
STOLEN (Replace)
MUTILATED (Replace)
NEVER RECEIVED
(Complete Section D)
2.
CLASS C
CLASS B
CLASS A
B
CHANGE OR CORRECTION ONLY (Important information on reverse side)
ADDRESS CHANGE -
A Post Office Box number may be used in addition to the actual residence address, but cannot be used as the only address.
See reverse if using an out-of-state address.
STREET ADDRESS
ZIP CODE
CITY
STATE
PA
If you are a registered voter in PA, would you like us to notify your county voter registration office of this change?
YES
NO
If you are not a registered voter, you may contact your county voter registration office.
NAME CHANGE
OTHER
REASON:
MARRIAGE
DIVORCE
(Please note all name changes must be done in person with original documents)
(see reverse side)
LAST NAME
JR., ETC.
FIRST NAME
MIDDLE NAME
OTHER CHANGES
EYE COLOR (Please check one):
BLUE
BROWN
GREEN
HAZEL
PINK
BLACK
GRAY
DICHROMATIC
OTHER _______________
CORRECTION OF DATE OF BIRTH
HEIGHT
SOCIAL SECURITY NUMBER
MONTH
DAY
YEAR
FEET
INCHES
C
AUTHORIZATION AND CERTIFICATION
For Veterans wishing to add the Veterans Designation to their Driver's License or ID Card: 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 all information given on this application 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. If using a Messenger Service, I hereby authorize the Department to
furnish them with my driving record for the purpose of processing this form. I hereby acknowledge this day that I have received notice of the provisions of Section 3709 of the Vehicle
Code. (See reverse for provisions.)
I wish to contribute $1.00 to the Organ Donation Awareness Trust Fund. (see reverse)
X
I wish to contribute $3.00 to the Veterans' Trust Fund. (see reverse)
WARNING: Misstatement of Fact is a misdemeanor of the
SIGN
third degree punishable by a fine of up to $2,500 and/or
HERE
imprisonment up to 1 year (18 PA. C.S. Section 4904(b)).
APPLICANT'S SIGNATURE IN INK
DATE
PAID BY:
Check
Money Order
Payable to PennDOT (PennDOT does not accept cast, credit or debit cards)
TOTAL $
E
NOTARY MUST BE COMPLETED IF PRODUCT NOT RECEIVED
MUST BE COMPLETED IF APPLICANT IS UNDER THE AGE OF 18
D
OR IF APPLICANT IS UNDER THE AGE OF 18
I hereby certify that I am
If you never received your Learner's Permit you are entitled to a free permit
ONLY if this application is completed within 90 days of the original date of
Parent,
Guardian,
Person in Loco Parentis, or
Spouse
issuance and the original was never received due to loss in the mail.
at least 18 years of age, of the applicant named herein,
SUBSCRIBED AND SWORN
that the statements made hereon are true and correct to the
best of my knowledge and that this application is made with
TO BEFORE ME:
MO.
DAY
YEAR
my full consent.
X
SIGNATURE OF PERSON ADMINISTERING OATH
SIGN
HERE
S
E
(Signature of Parent, Guardian, Person in Loco Parentis or Spouse at least 18 years of age)
SIGN IN PRESENCE OF NOTARY
A
L
(Print Name as it Appears in Signature Above)
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