Form Dl-80 2005 - Non-Commercial Driver'S License Application For Change / Correction / Replacement
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2DL-80 (10-06)
NON-COMMERCIAL DRIVER'S LICENSE
PA Department of Transportation
Bureau of Driver Licensing
APPLICATION FOR
P.O. Box 68272
CHANGE / CORRECTION / REPLACEMENT
Harrisburg, PA 17106-8272
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE.
if
CHANGE or CORRECTION of Non-Commercial License.
CHECK
REPLACEMENT (DUPLICATE) — Complete Sections A, B, (C & D
APPLICABLE
applicable)
, E and F. All requests must be notarized. Complete
Complete Section A, C and F. Notarization is not
BLOCK:
absence statement on reverse side if applicable.
required. An update card will be issued.
A
YOU MUST COMPLETE ALL PARTS OF SECTION A
DRIVER'S LICENSE NUMBER
LAST NAME
JR/ETC
FIRST NAME
MIDDLE NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
TELEPHONE NUMBER (8:00 A.M.-4:30 P.M.)
EMAIL ADDRESS
Month
Day
Year
-
-
(
)
ORGAN DONOR
B
( REASON - Check One)
REPLACEMENT REQUIRED DUE TO
:
APPLICATION FOR REPLACEMENT (CHECK ONE)
DESIGNATION
MUTILATED
LOST
REGULAR CAMERA CARD
PHOTO LICENSE
UPDATE CARD
ADD (Parental consent in
STOLEN
SURRENDERED OUT-OF-STATE
Section D required if
STATEMENT ON REVERSE
*
*
''PHOTO-EXEMPT''
VALID W/O
under 18)
NEVER REC'D
OTHER ____________________
MUST BE COMPLETED
CAMERA CARD
PHOTO LICENSE
__________________________
REMOVE
AND SIGNED
CORRECTION
C
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.
NEW
STREET
ADDRESS
STATE
PA
ZIP CODE
CITY
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
REASON:
MARRIAGE
DIVORCE
OTHER (see reverse side)
JR., ETC.
MIDDLE NAME
FIRST NAME
LAST
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
DROP PRIVILEGE:
SEX
FEET
INCHES
MONTH
DAY
YEAR
-
-
Class M
MALE
FEMALE
CONSENT OF PARENT, GUARDIAN, PERSON IN LOCO PARENTIS OR SPOUSE AT LEAST 18 YEARS OF AGE. Complete if
D
Applicant is less than 18 years of age to give consent for Applicant's request for Organ Donor Designation.
I hereby certify that I am a
Parent,
Guardian,
Person in Loco Parentis
Spouse at least 18 years of age and I:
Do give consent
Do not give consent for applicant's request for Organ Donor designation.
X
SIGN
HERE
(SIGNATURE OF PARENT, ETC.)
No person may hold more than one valid license at any time. If you have a license from another state, do not use this form. YOU MUST
E
go to a Driver License Examination Center to surrender your out-of-state license and make application for a replacement PA license.
1.
YES
NO - Is your driver's license or driving privilege suspended or revoked in this state or any other state?
2.
YES
NO - Have you been arrested or cited in this state or any other state for any violation which carries a possible penalty of
suspension or revocation of your driver's license or driving privilege?
If yes, give state_________ Date ______________ and Reason _________________________________________________
F
AUTHORIZATION AND CERTIFICATION
AFFIDAVIT: This section must be notarized when applying for replacement
I certify under penalty of law that all information given on this application is true and correct. I
(duplicate) Non-Commercial License or Camera Card. You are entitled to a free
hereby authorize the Social Security Administration to release to the Department of Transportation
replacement ONLY if this application is completed within 90 days of the original
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
date of issuance and the original was never received due to loss in the mail.
record for the purpose of processing this form. I hereby acknowledge this day that I have received
SUBSCRIBED AND SWORN
notice of the provisions of Section 3709 of the Vehicle Code.
FEE PAID
TO BEFORE ME:
MO.
DAY
YEAR
(See reverse for provisions.)
Send Check
I wish to contribute $1.00 to the Organ
In This
Signature of Person Administering Oath
Amount
Donation Awareness Trust Fund
(see reverse).
S
SEE REVERSE FOR FEES
X
SIGN
E
WARNING: Misstatement of fact is
SIGN IN PRESENCE OF NOTARY
a misdemeanor of the third degree
A
HERE
punishable by a fine of up to $2,500
L
and/or imprisonment up to 1 year
(18 PAC.S. Section 4904(b)).
(APPLICANT'S SIGNATURE IN INK)
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