Form Dl-80cd - Commercial Drivers License Application To Replace/correct
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2DL-80CD (12-10)
COMMERCIAL DRIVER’S LICENSE
APPLICATION TO REPLACE/CORRECT
D E PA R T M E N T O F T R A N S P O R TAT I O N
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION
Bureau of Driver Licensing • P.O. Box 68272 • Harrisburg, PA 17106-8272
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION. PLEASE READ IMPORTANT INFORMATION ON THE BACK.
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.)
E-MAIL ADDRESS
Month
Day
Year
REPLACEMENT REQUIRED DUE TO:
B
APPLICATION FOR REPLACEMENT (Check One)
ORGAN DONOR
Lost
Stolen
DESIGNATION
CDL Learner's Permit and/or Knowledge Test Authorization
Mutilated
Change of Address
(MUST BE NOTARIZED)
CDL Camera Card (If checked, form MUST BE NOTARIZED)
Correction
ADD
CDL Photo License
Extreme physiological changes in appearance
REMOVE
Never Received (MUST BE NOTARIZED - No
School Bus Driver Endorsement Card
Fee Required)
CHANGE OR CORRECTION ONLY (Important information on reverse side)
C
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
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
REASON:
MARRIAGE
DIVORCE
OTHER (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
DROP PRIVILEGE:
MONTH
DAY
YEAR
FEET
INCHES
Class M
Hazmat Endorsement
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 go
D
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 ______________________________________________
E
AUTHORIZATION AND CERTIFICATION
THIS SECTION MUST BE NOTARIZED
I certify under penalty of law that all information given on this application is true and correct. I hereby authorize
AFFADAVIT: This section must be notarized when applying for replacement
the Social Security Administration to release to the Department of Transportation information concerning my
(duplicate) Commercial License or Camera Card. You are entitled to a free
Social Security Identification Number for the purpose of identification. If using a Messenger Service, I hereby
replacement ONLY if this application is completed within 90 days of the original
authorize the Department to furnish them with my driving record for the purpose of processing this form. I hereby
date of issuance and the original was never received due of loss in the mail.
acknowledge this day that I have received notice of the provisions of Section 3709 of the Vehicle Code.
SUBSCRIBED AND SWORN
(See reverse for provisions.)
MO
DAY
YEAR
TO BEFORE ME:
FEE PAID
I wish to contribute $1.00 to the Organ Donation
Send Check In
Awareness Trust Fund (see reverse).
This Amount
Signature of Person Administering Oath
SEE REVERSE FOR FEES
X
S
WARNING: Misstatement of fact is a misdemeanor
SIGN
E
of the third degree punishable by a fine of up to
SIGN IN PRESENCE OF NOTARY
$2,500 and/or imprisonment up to 1 year (18 PA C.S.
A
HERE
Section 4904(b)).
L
APPLICANT’S SIGNATURE IN INK
THIS FORM MAY BE DUPLICATED
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