Form Dl-901 - Non-Commercial Driver'S License / Identification Card / Learner'S Permit Application To Renew / Replace / Change / Correct

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DL-901 (4-14)

NON-COMMERCIAL DRIVER'S LICENSE /

IDENTIfICATION CARD / LEARNER'S PERMIT

APPLICATION TO RENEw / REPLACE / CHANGE / CORRECT

Bureau of Driver Licensing • P.O. Box 68272 • Harrisburg, PA 17106-8272

MUST CHECK ONE:

DRIVER'S LICENSE

LEARNER'S PERMIT

IDENTIfICATION CARD

YOU MUST COMPLETE ALL PARTS Of SECTION A

JR./ETC

LICENSE/PERMIT/ID NUMbER

LAST NAME

fIRST NAME

MIDDLE NAME

E-MAIL ADDRESS (if applicable)

DATE OF BIRTH

TELEPHONE NUMbER (

8:00A.M. - 4:30P.M.)

MONTH

DAY

YEAR

REASON

ORGAN DONOR

( * must be notarized)

PRODUCT NEEDED

DESIGNATION

*CAMERA CARD (See reverse for notarization)

ADD/eXTeND

reNeW

SToLeN

MuTILATeD

ADD

LICeNSe/ID CArD

LeArNer'S PerMIT

uPDATe CArD

* NEVER RECEIVED

LoST

ChANge/CorreCT

Do NoT ADD

MoTorCyCLe (license only renewal) NoTe: Class M information see reverse

oTher

reMoVe

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.

STREET ADDRESS

STATE

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

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.

LAST NAME

fIRST NAME

mIDDLe name

oTheR changeS

EYE COLOR

(Please check one):

bLUE

bROwN

GREEN

HAZEL

PINK

bLACK

GRAY

DICHROMATIC

OTHER ________________

HEIGHT

SOCIAL SECURITY NUMbER

coRRecTIon of DaTe of BIRTh

DRoP PRIvILege

feeT

INCheS

MoNTh

DAy

yeAr

DRoP cLaSS m

MUST bE COMPLETED If APPLICANT IS UNDER THE AGE Of 18 APPLYING fOR A LEARNER'S PERMIT OR ORGAN DONOR DESIGNATION

I hereby certify that I am a

Parent,

guardian,

Person in Loco Parentis, or

Spouse at least 18 years of age, of the applicant

named herein, that the statements made hereon are true and correct to the best of my knowledge and that this application is made with

my full consent.

SIgn

heRe

(SIGNATURE OF PARENT, GUARDIAN, Person in Loco Parentis, or Spouse at least 18 years of age.)

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

foR

go to a Driver License Examination Center to surrender your out-of-state license and make application for a replacement PA license.

DRIveR'S

yeS

No - Do you hold a valid driver's license issued by any other state?

LIcenSe

yeS

No - Is your driver’s license or driving privilege suspended or revoked in this state or any other state?

anD

yeS

No - Do you have any pending criminal charges or driving violations in this state or any other state which may carry a possible penalty

LeaRneR'S

of suspension or revocation of your driver's license or driving privilege?

PeRmIT

If yes to any question, give state _______ Date ____________ and reason _________________________________________________________

AUTHORIZATION AND CERTIfICATION

NOTARY (see instructions on back)

Veterans Designation: I certify under penalty of law that I am a qualified applicant and hereby request it be added to my

SUbSCRIbED AND SwORN TO bEfORE

product. I understand that misrepresentation will result in the cancellation of my driver's license and/or identification card.

ME:

MO.

DAY

YEAR

I certify under penalty of law that all information given on this application is true and correct. I hereby authorize the

Social Security Administration to release to the Department of Transportation information concerning my Social Security

SIgNATure of PerSoN ADMINISTerINg oATh

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 purpose of processing this form. I hereby acknowledge this day that I have

received notice of the provisions of Section 3709 of the Vehicle Code. (See reverse for provisions.)

I wish to contribute $1.00 to the organ Donation Awareness Trust fund.(see reverse)

fEE

I wish to contribute $3.00 to the Veterans' Trust fund. (see reverse)

SIgn

PRESENCE Of NOTARY

See ReveRSe foR feeS

heRe

Applicant's Signature in Ink

(Date)

wARNING: Misstatement of fact is a misdemeanor of the third degree punishable of up to $2,500 and/or imprisonment up to 1 year (18 Pa C.S. Section 4904(b)).