Form Dl-54a - Application For Initial Identification Card
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1
2DL-54A (8-15)
ApplicAtion for initiAl iDEntificAtion cArD
Bureau of Driver Licensing • P.O. Box 68272 • Harrisburg, PA 17106-8272
ALL SECTIONS MUST BE COMPLETED
A
Jr./etc
LaSt name
middLe name
firSt name
Sex
telephone number
date of birtH
HeigHt
S OCIAL SECURITY NUMBER OR dRIvER'S LICENSE NUMBER
(8:00 a.m. to 4:30 p.m.)
montH
dAY
YEAR
feet
incHeS
EYE COLOR (please check one): BLUE
BROWN
GREEN
HAZEL
PINK
BLACK
GRAY
DICHROMATIC
OTHER
_________________________
CURRENT STREET AddRESS - A Post Office Box number may be used in addition to the actual residence address, but cannot be used as the only address.
PA
State
ZIP COdE
CITY
If this is a change of address and you are a registered voter in PA, would
If you are not a registered voter, you may
YES
NO
you like us to notify your county voter registration office of this change?
contact your county voter registration office.
do you hold a current/valid out-of-state driver's license?
If yes, you must surrender your out-of-state valid license.
YES
NO
B
CHECK APPLICABLE BLOCK BELOW:
FEE INFO.
1.
I hAvE NEvER hELd A PA dRIvER'S LICENSE/PERMIT OR IdENTIfICATION CARd ANd I AM APPLYINg fOR AN
$28.50
initiaL identification card. (You must apply in person at any Driver License Center.)
2.
I CURRENTLY hOLd A PA dRIvER'S LICENSE/PERMIT ANd AM APPLYINg fOR A NON-dRIvER IdENTIfICATION
card for tHe foLLoWing reaSon:
free
i am surrendering my driving privilege for health reasons that may affect my ability to safely operate a motor vehicle.
i understand that my license will not be reissued until i successfully complete the appropriate examination.
(If you have not
already surrendered your Driver's License/ Learner's Permit, please attach it to this application.)
i am voluntarily surrendering my driving privilege with the understanding that it will be retained for a minimum of six
months as required by 67 Pa. Code 93.2. It is understood that I will not be permitted to apply for my driver's license,
$28.50
Class A through M inclusive, for a period of six months. (Attach driver's License/ Learner's Permit.)
A VOLUNTARY
SURRENDER WILL NOT BE ACCEPTED AS CREDIT TOWARD A SUSPENSION, RECALL, CANCELLATION, OR REVOCATION.
As a result of my parent's or guardian's withdrawal of consent for me to drive a motor vehicle (Attach driver's License/
$28.50
Learner's Permit.)
PLEASE NOTE: A DL-100A MUST ACCOMPANY THIS APPLICATION.
As a result of the suspension of my driver's license. License MUST be attached. If not, you MUST complete the
ACKNOWLEDGEMENT: I ________________________________________________________________________________________
(PRINT NAME)
hereby acknowledge that my driving privilege is suspended/revoked/disqualified in Pennsylvania and my
A.
License issued by Pennsylvania has expired.
B.
License issued by Pennsylvania has been:
Lost
Stolen
mutilated
$28.50
When?______________________ How? ________________________________________________________________
C.
License issued by Pennsylvania has been surrendered to or confiscated by the Police/Court.
When?______________________ What Police department/County? _______________________________________
d.
License issued by Pennsylvania has been previously surrendered to PenndOT to serve an existing period of suspension.
When? ______________________ Why were you suspended? ____________________________________________
3.
$28.50
i dESIRE TO hAvE AN IdENTIfICATION CARd ALONg WITh MY CURRENT/ExPIREd PA dRIvER'S LICENSE/PERMIT.
C
CERTIFICATION (SIGN AND ENTER DATE OF APPLICATION)
REqUEST FOR ORGAN DONOR DESIGNATION
PARENTAL CONSENT
Veterans Designation: I certify under penalty of law that I am a qualified applicant and hereby
I am under the age of 18 years and I hereby request Organ donor
request it be added to my product. i understand that misrepresentation will result in
designation on my Pennsylvania I.d. Card. Applicants 18 years of age
the cancellation of my identification card.
or older will have the opportunity to request organ donor designation
i certify under penalty of law that all information given on this application is true and correct. i hereby
at the Photo driver's License Center at the time they have their photo
authorize the Social Security administration to release to the department of transportation information
taken.
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
i hereby certify that i am a
Parent,
guardian,
purpose of processing this form.
Person in Loco Parentis, or
Spouse at least 18 years of age and
I wish to contribute $1.00 to the Organ donation Awareness Trust fund (see reverse).
i:
do give consent
I wish to contribute $3.00 to the veterans' Trust fund (see reverse).
do NOT give consent for applicant's request for Organ
donor designation.
X
SIGN
X
HERE
SIGN
APPLICANT'S SIgNATURE IN INk
dATE
HERE
WARNINg: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500 and/or
imprisonment up to 1 year (18 Pa. C, Section 4904 [b]).
SIgNATURE Of PARENT, gUARdIAN, PERSONS IN LOCO PARENTIS, OR SPOUSE AT LEAST 18 YEARS Of AgE
dATE
D
DEPARTMENTAL USE ONLY
ID NUMBER ______________________________________________
RESIDENCY REqUIREMENTS (LIST TWO) 1. ________________________________________ 2. _________________________________________
VERIFICATION OF BIRTH DATE & IDENTITY
Birth certificate
Other _________________________________________________________
X
SIGN
HERE
Signature of examiner
date
badge no.
exam center
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