Form Dl-180 - Non-Commercial Learner'S Permit Application Page 2
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3DL-180 (7-17)
FOR OFFICIAL USE ONLY
COMPLETED BY HEALTH CARE PROVIDER OR DRIVER LICENSE EXAMINER
COMPLETED BY DRIVER LICENSE EXAMINER ONLY
YES NO
EXAMINER'S DRIVER CERTIFICATION
CHECK (3 )
VISION SCREENING
COMPLETE ALL ITEMS
This is to certify that the above applicant has applied for and passed the
Uncorrected
Corrected
20/40 vision or less in better eye with correction ..........
examination for the above class(es) for a Pennsylvania Driver's License.
20/
Right Eye
20/
Report of Eye Examination (attached)......................
20/
20/
Left Eye
_____________________________________
___________
20/
Qualified Without Restrictions
20/
Both Eyes
(SIGNATURE OF EXAMINER)
(DLE NO.)
R
L
Fields
R
L
Qualified With Restrictions
DATE OF ISSUE:
MONTH
DAY
YEAR
Corrective Lenses
Other: ______________________________________________
________________________________________________________________
EXAM CENTER:
(PROVIDER SIGNATURE)
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'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)
• Original USCIS/immigration documents indicating current lawful
immigration status
AND ONE of the following:
• Valid Passport, dependent on status
( U.S. issued by an authorized
• Birth Certificate with raised seal
government agency, including U.S. territories or Puerto Rico.) No
• Social Security Card or SSA ineligibility letter (must be original;
other birth documents will be accepted.
card cannot be laminated)
(BCIS/INS Form N-560)
• Certificate of U.S. Citizenship
(Please note: Documents must be original, photo copies will not
be accepted.)
(BCIS/INS Form N-550 or N-570)
• Certificate of Naturalization
To obtain detailed information regarding "identity/residency
• Valid U.S. Passport (Only valid U.S. Passports and original
requirements," you can:
documents will be accepted.)
• Visit ,"
NOTE:
If you have an Out-of-State Driver's License, you should
and review required documents; or
present it along with your Social Security Card and one of the
above forms.
• Contact us at 1-800-932-4600 or 1-800-228-0676 (TDD)
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.)
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