Form Dl-80 2011 - Non-Commercial Drivers License Application For Change / Correction / Replacement Please Type Or Print In Blue Or Black Ink All Information
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2DL-80 (3-11)
NON-COMMERCIAL DRIVER’S LICENSE
APPLICATION FOR CHANGE / CORRECTION / REPLACEMENT
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION
Bureau of Driver Licensing • P.O.Box 68272 • Harrisburg, PA 17106-8272
PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE.
CHECK
CHANGE OR CORRECTION of Non-Commercial License.
REPLACEMENT (DUPLICATE) – Complete Sections A, B, (C & D if applicable),
APPLICABLE
Complete Section A, C and F. Notarization is not required.
E and F. All requests marked with an asterisk (*) MUST be notarized.
BLOCK:
An update card will be issued.
Complete absence statement on reverse side if applicable.
A
YOU MUST COMPLETE ALL PARTS OF SECTION A
DRIVER’S LICENSE NUMBER
LAST NAME
JR./ETC
FIRST NAME
MIDDLE NAME
E-MAIL ADDRESS (if applicable)
TELEPHONE NUMBER (
8:00A.M. - 4:30P.M.)
DATE OF BIRTH
MONTH
DAY
YEAR
B
APPLICATION FOR REPLACEMENT (CHECK ONE)
REPLACEMENT REQUIRED DUE TO REASON (CHECK ONE)
ORGAN DONOR
DESIGNATION
*REGULAR CAMERA CARD
PHOTO LICENSE
UPDATE CARD
LOST
MUTILATED
ADD
(parental consent in
STOLEN
CORRECTION
Section D required
*“PHOTO-EXEMPT’’ CAMERA CARD
VALID W/O PHOTO LICENSE
*NEVER RECEIVED
OTHER ______________________
if under 18)
(No Fee Required)
_____________________________
REMOVE
(STATEMENT ON REVERSE MUST BE COMPLETED AND SIGNED)
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
PA
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
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)
MIDDLE NAME
JR., ETC.
FIRST NAME
LAST
OTHER CHANGES
EYE COLOR
BLUE
BROWN
GREEN
HAZEL
PINK
BLACK
GRAY
DICHROMATIC
OTHER ________________
(Please check one):
CORRECTION OF DATE OF BIRTH
HEIGHT
SOCIAL SECURITY NUMBER
DROP PRIVILEGE
FEET
INCHES
MONTH
DAY
YEAR
DROP CLASS M
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.
X
I hereby certify that I am a
SIGN
Parent,
Guardian,
Person in Loco Parentis
Spouse at least 18 years of age and I:
HERE
Do give consent
Do not give consent for applicant’s request for Organ Donor Designation.
(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 go
E
ALL MUST BE
to a Driver License Examination Center to surrender your out-of-state license and make application for a replacement PA license.
ANSWERED IF
1.
YES
NO - Is your driver’s license or driving privilege suspended or revoked in this state or any other state?
REPLACEMENT
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?
IS REQUESTED
If yes, give state_________ Date ______________ and Reason ___________________________________________________________
F
AUTHORIZATION AND CERTIFICATION
I certify under penalty of law that all information given on this application is true and correct. I hereby
AFFIDAVIT: This section must be notarized when applying for replacement of a
authorize the Social Security Administration to release to the Department of Transportation information
Camera Card. You are entitled to a free replacement ONLY if this application is
concerning my Social Security Identication Number for the purpose of identication. If using a Messenger
completed within 90 days of the original date of issuance and the original was
Service, I hereby authorize the Department to furnish them with my driving record for the purpose of
never received due to loss in the mail.
processing this form. I hereby acknowledge this day that I have received notice of the provisions of Section
SUBSCRIBED AND SWORN
3709 of the Vehicle Code. (See reverse for provisions.)
Fee Paid
TO BEFORE ME:
MO.
DAY
YEAR
Send Check
I wish to contribute $1.00 to the Organ Donation
In This
Signature of Person Administering Oath
Amount
Awareness Trust Fund (see reverse).
SEE REVERSE FOR FEES
S
X
WARNING: Misstatement of fact is
E
SIGN
SIGN IN PRESENCE OF NOTARY
a misdemeanor of the third degree
A
punishable by a fine of up to $2,500
HERE
and/or imprisonment up to 1 year
L
(18 PA C.S. Section 4904(b)).
(APPLICANT’S SIGNATURE IN INK)
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