Form Dl-80 2005 - Non-Commercial Driver'S License Application For Change / Correction / Replacement Page 2

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DL-80 (10-06)

The most current version of this form can be found at:

APPLICANT INFORMATION

• Photo Exemption: Complete form as indicated. Sign both Section ''F'' and the statement below. PennDOT will send you a camera card and

REQUEST FOR EXEMPTION FROM PHOTO

further instructions.

ABSENTEE EXEMPTION

RELIGIOUS EXEMPTION

During the next 60 days I will be absent from PA for the following reason:

I hereby request an exemption from having my photo taken because of

my religious affiliation with: ___________________________________

Military

School

Work

Travel

NAME OF RELIGIOUS GROUP

Within 45 days of my return I will apply for a driver's license containing

my photo.

My religious beliefs forbid the taking of photographs.

X ________________________________________________________

SIGNATURE HERE

• Religious Exemptions: If requesting a religious exemption, a letter must accompany this application that includes:

A. The request for the exemption;

B. The name of the religious group to which the applicant is affiliated;

C. A statement that the religion's belief forbids the taking of photographs; and,

D. The applicant's signature.

• Out-of-State Address Change: We may not issue driver license products to an out-of-state address, except in the case of an employee of federal

or state government, armed forces personnel, or their families, whose workplace is located outside of Pennsylvania. If this exception applies to

you, please check the appropriate box and include documentation of your status with this application.

Attach a letter from your employer on their letterhead to document your status, or attach a copy of your current Photo ID issued by your

employer. If you are the immediate family of a person meeting one of the allowable exceptions, attach the documentation of the person

employed. Additionally, you must indicate your relationship to that person.

I certify that my workplace is located out of state and I am employed by, or am the immediate family of a person employed by:

US Armed Forces

Federal Government

Pennsylvania State Government

Relationship to person meeting exemption (check one):

Spouse

Dependent Child

• Return your completed and signed application with check or money order made payable to "PennDOT", to: Bureau of Driver Licensing, P.O. Box

68272, Harrisburg, PA 17106-8272.

• If your license is due to expire within six (6) months, DO NOT use this form. Complete form DL-143 (Renewal of a Non-Commercial Driver License).

• If you find or recover your original license after you have submitted this application for a duplicate, return the original license with a letter of

explanation to: Bureau of Driver Licensing, P.O. Box 68615, Harrisburg, PA 17106-8615. After duplicate is issued, the original license is no

longer valid.

REPLACEMENT OF

APPLICATION FOR REPLACEMENT MUST BE NOTARIZED IN SECTION F

NON-COMMERCIAL

*FEE: $10.00 - The Bureau will issue a camera card, which is a temporary Non-Commercial Driver's License

PHOTO OR VALID W/O

valid for 60 days. During those 60 days, the driver must appear at a photo driver license center for the purpose of

PHOTO NON-COMMERCIAL

having a photo taken. If photo image is on file, the Bureau will issue a Photo Driver's License.

DRIVER'S LICENSE

*If license is endorsed with Class M, fee is $15.00 .

REGULAR OR ''PHOTO

*FEE: $5.00 if photo was not taken with the original camera card.

EXEMPT''CAMERA CARD

*If license is endorsed with a Class M, fee is $10.00.

UPDATE CARD

No Fee.

ORGAN DONOR

When you are adding or removing the Organ Donor designation, the form must be notarized and a duplicate

DESIGNATION

fee is required. Refer to fees above.

ORGAN DONATION

You have the opportunity to contribute $1.00 to the Fund. The additional $1.00 contribution must be added to

AWARENESS TRUST FUND

the fees above and included in your payment by check/money order. You must also check the block provided

(ODTF)

in Section F to ensure proper handling of your contribution.

NO FEE REQUIRED — The Bureau will issue an update card reflecting the change/correction which must be carried with

CHANGE/CORRECTION

the driver's license. Notarization is not required.

ONLY

IF NAME IS CHANGED by permission of court, attach a Certified Copy of the Court Order. If you desire to use a name other than your (1) birth

name, (2) spouse's surname, or (3) a name given through a court order, you must provide a copy of a Social Security Card (or records), together

with copies of documents from two other sources issued in the desired name such as: Tax Records, Selective Service Card, Voter Registration

Card, Passport, or any form of Photo I.D. issued by a governmental agency.

IF YEAR OF BIRTH on driver's license is incorrect, attach official birth certificate.

IF Social Security Number is incorrect, attach copy of Social Security Card.

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, househol d 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.

For any violation of Section 3709, I may be subject to a fine of up to $300 upon conviction, including any violation resulting from the conduct of any other persons

present within any vehicle of which I am the driver.