pA dRiVeR'S liceNSe/peRmit NumBeR |
lASt NAme |
JR.,etc. |
fiRSt NAme |
middle NAme |
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dAte of BiRtH (must be listed) |
telepHoNe NumBeR |
e-mAil AddReSS (if applicable) |
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month |
day |
year |
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CHANGE OR CORRECTION ONLY
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.
New
StReet
AddReSS
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. |
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You mUSt mark the appropriate box(es) and provide the requested information.
1.❑ Never licensed in Pennsylvania.
2.License, Permit(s) and/or Camera Card issued by Pennsylvania is:
❑Expired
❑Lost
❑Stolen
❑Mutilated: When?_______________________________________________________________________________________
❑Surrendered to or confiscated by the Police. When: ______________________________________
What Police Department? ________________________________________________________________________________
3.❑ Other: You must indicate the reason that you are unable to surrender your valid License, Permit(s) and/or Camera
Card if items 1 or 2 do not apply: (If you have a valid PA Driver's License you may not retain it for photo identification
purposes): _______________________________________________________________________________________________
_________________________________________________________________________________________________________
Acknowledgment
I, ____________________________________ hereby acknowledge that my driving privilege is Suspended/Revoked/Disqualified in Pennsylvania.
And
I certify that all information given on this acknowledgment is true and correct and hereby apply for proper credit. I understand that upon restoration, I will be required to apply for the issuance, renewal, or replacement of my Driver's License, Learner's Permit, or Camera Card, whichever is needed, in order to be licensed in Pennsylvania. If using a messenger service, I hereby authorize the Department to furnish them with my driving record for the purpose of processing this form.
X |
__________________________________ |
SIGNATURE IN INK |
DATE |
wARnIng: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500.00 and/or imprisonment up to one year (18 PA C.S. Section 4904(b)).
AddItIonAl InFoRmAtIon
Unless this document is being submitted by a Court of Record following sentencing, this form must be mailed to:
Penndot • Bureau of driver licensing • P.o. Box 68693 • Harrisburg, PA 17106-8693
Upon receipt, review and acceptance of this acknowledgment, PennDOT will send you a receipt confirming the date that credit began. If you do not receive this receipt within 3 weeks of your mailing, please contact PennDOT at the telephone numbers listed below to verify that credit has begun:
InFoRmAtIon mondAY tHRoUgH FRIdAY (8:00 a.m. to 5:00 p.m.)
✦ In State: 1-800-932-4600 ✦ tdd: 1-800-228-0676 ✦ out-of-State: 1-717-412-5300 ✦ tdd out-of-State: 1-717-412-5380
