Dl 180R Form PDF Details

In understanding the facets of evolving legal and identification requirements within the United States, the DL-180R form emerges as a critical document for non-commercial drivers transitioning their driving credentials to Pennsylvania from other states. This comprehensive form not only facilitates the application process for a Pennsylvania Non-Commercial Driver's License but also intricately binds an applicant's submission to several legal declarations and consent protocols. It mandates the disclosure of personal identification details such as social security numbers, height, and eye color—data collected under specific sections of the Pennsylvania Vehicle Code to combat license fraud effectively. Moreover, the form embraces inclusivity and respect for individual identity by allowing applicants to select a gender designation that reflects their true identity, with a strict warning against fraudulent representation. Emphasized within the DL-180R is the option for organ donor designation, underlining Pennsylvania's support for this life-saving choice. Applicants are put through a sieve of legal certifications regarding past driving records, medical conditions that might impair driving abilities, and a clear acknowledgment of the legal ramifications of misinformation. Furthermore, the form opens avenues for contributions towards organ donation awareness and veterans' support, reflecting a blend of legal procedure with societal welfare. Additionally, it spells out the necessity for a physical presence during the application, a surrender of out-of-state licenses, and the correlation of application acceptance with one's driving record, underscoring a strict adherence to legal and safety standards. The legal ramifications of non-compliance or fraudulent attempts are delineated with specificity, illustrating the form's role not just as a procedural necessity but as a gateway to responsible and legal driving in Pennsylvania.

QuestionAnswer
Form NameDl 180R Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdl 180r, dl 180 r, dl 180r form, dl180r

Form Preview Example

DL-180R (2-20)

 

APPLICATION FOR PENNSYLVANIA

 

 

 

 

 

 

 

 

NON-COMMERCIAL DRIVER'S LICENSE BY

 

 

 

 

 

 

 

 

OUT-OF-STATE NON CDL DRIVER

 

 

 

 

YOU MUST APPLY IN PERSON

 

A

LAST NAME (S)

 

 

 

 

 

 

 

 

 

 

 

 

  JR., ETC.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

  MIDDLE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

HEIGHT

 

SOCIAL SECURITY NUMBER

 

TELEPHONE 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____________________

 

 

SEX/GENDER DESIGNATION STATEMENT

 

 

 

 

 

 

 

 

 

 

I,

 

 

 

 

 

 

wish the gender designation on my Driver’s License/ ID Card to read

 

 

 

 

 

 

(PRINT NAME)

 

FEMALE (F)

Non-Binary (X)

 

 

 

 

 

 

 

 

 

 

 

 

 

MALE (M)

 

 

 

 

 

 

 

I hereby certify under penalty of law that this request for the selected gender designation to appear on my Driver’s License/ ID Card accurately reflects my gender identity and is not for any fraudulent or other unlawful purpose.

 

 

STREET ADDRESS: A Post Office Box number may be used in addition to the actual residence address, but

CITY

 

 

STATE ZIP CODE

 

 

 

 

 

cannot be used as the only address.

 

 

 

 

 

 

 

 

 

The Department is required to obtain the Licensee's Social Security Number, height and eye color under the provisions of Section 1510(a) and/or 1609(a)(4) of the Pennsylvania Vehicle Code. This information will be used as identifying information in an attempt to minimize driver license fraud. Federal law permits the use of the Social Security Number by state licensing officials for purposes of identification.

ORGAN DONOR DESIGNATION: Pennsylvania strongly supports organ and tissue donation because of its life-saving and life-enhancing opportunities. ADD (Parental consent in Section C required if under 18) REMOVE

 

 

B

ALL STATEMENTS MUST BE ANSWERED Please check only the boxes that apply to you, that would prevent you from having reasonable control of a motor vehicle.

 

 

Neurological disorders

Neuropsychiatric disorders

Circulatory disorder

Cardiac disorder

Hypertension

 

 

Uncontrolled Epilepsy

Uncontrolled Diabetes

Cognitive Impairment

Alcohol abuse

Drug abuse

 

 

Conditions causing repeated lapses of consciousness (e.g. epilepsy, narcolepsy, hysteria, etc.)

 

 

 

 

Specify: ________________________________________________________________________________ If seizure disorder, date of last seizure:____________

 

 

Impairment or Amputation of an appendage. If so, list:_________________________________________________________________________________________

 

 

Other:_ ______________________________________________________________________________________________________________________________

 

 

 

NOTE: Any recommendations/additional comments must accompany this certificate on a health care provider’s letterhead.

 

THIS DEPARTMENT MAY REQUIRE A PHYSICAL EXAMINATION BY A PROVIDER OR CAUSE.

 

Check Applicable Block YES NO

1.

Have you ever held a PA Driver's License/Learner's Permit/ID Card in this or any other name(s)?

. . . . . . 對

 

If yes, what was your previous record number and/or name(s)_______________________________________________________________________________

2.

Have you ever held or possessed a Driver's License (DL)/Learner's Permit (LP)/Photo Identification Card (ID) from any other state?

 

 

If yes, State: _____

DL/LP/ID #: _____________________ Name if different than above: __________________________________________________________________

 

 

State: _____

DL/LP/ID #: _____________________ Name if different than above: __________________________________________________________________

 

 

State: _____

DL/LP/ID #: _____________________ Name if different than above: __________________________________________________________________

3. Is your right to apply for a license or your privilege to operate a vehicle in this or any other state currently suspended or revoked?. . . . . . . . . . . . . .

If yes, give state _______ date  ____________ reason _ __________________________________________________________________________________

4. Do you have any pending criminal charges or driving violations in this state or any other state which may carry a possible penalty of suspension or revocation. . .

of your driver's license or driving privilege? If yes, give state _________ date  _______________ reason __________________________________________

5. Are you currently required, or have you been cited for a violation that will require you, to only drive vehicles equipped with an Ignition Interlock device? . . . . .

CCONSENT OF PARENT, GUARDIAN, PERSON IN LOCO PARENTIS OR SPOUSE AT LEAST 18 YEARS OF AGE (Complete if Applicant is Less Than 18 Years of Age.) 

I hereby certify that I am 

Parent, 

Guardian, 

Person in Loco Parentis or 

Spouse at least 18 years of age, of the applicant named herein, that the statements made

herein are true and correct to the best of my knowledge and that this application is made with my full consent.

I do give consent

 

 

 

SIGN

 

 

 

 

HERE

I do not give consent for applicant's request for Organ Donor designation.

X

 

 

 

 

 

(signature of parent, guardian, person in loco parentis or spouse at least 18 years of age - in ink)

 

DAUTHORIZATION AND CERTIFICATION

For Veterans wishing to add the Veterans Designation to their Driver's License or ID Card: I certify under penalty of law that I am a qualified applicant and hereby request it be added to my product. I understand that misrepresentation will result in the cancellation of my driver's license.

I acknowledge that receiving a Pennsylvania Permit, License or ID card will cancel or invalidate any Permit, License or ID card from another state. I certify under penalty of law that the information contained herein is true and correct. I hereby authorize the Social Security Administration to release to the Department of Transportation information 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 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 back for provisions.) 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.S. Section 4904 [b]).

 

 

I am under the age of 18 years and I hereby request Organ Donor designation on my PA Driver's License. (Applicant's 18 years of age or older will have the opportunity to request

 

 

Organ Donor designation at the Photo Center at the time they have their photo taken.)

 

SIGN

 

 

 

 

 

 

 

 

 

 

I wish to contribute $3.00 to the Organ Donation Awareness Trust Fund (see reverse).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(APPLICANT'S SIGNATURE IN INK)

(DATE)

 

 

PAID BY:

 

Debit/Credit Card

 

Check

 

 

 

Money Order

Payable to PennDOT (PennDOT Driver License

 

TOTAL

 $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Centers do not accept cash)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

EXAM REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXAMINER'S DRIVER CERTIFICATION

 

 

 

 

 

 

 

 

COMPLETE ALL ITEMS

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

This is to certify that the above applicant has applied for and passed the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  VISION SCREENING

CHECK ( ) YES   NO

 

Uncorrected

 

 

 

 

Corrected

 

examination for the above class(es) for a Pennsylvania Driver's License.

 

 

Combined vision is 20/40 or better

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20/

 

 

 

Right Eye

 

20/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Report of Eye Examination (attached)

 

20/

 

 

 

Left Eye

 

20/

 

 

 

 

_________________________________________ ____________

 

 

 

Qualified with Restrictions

 

 

 

 

 

20/

 

 

 

Both Eyes

 

20/

 

 

 

 

DATE OF ISSUE:

(SIGNATURE OF EXAMINER)

 

 

(DLE NO.)

 

 

Corrective Lenses

 

 

 

 

 

R 

L

Fields

 

R 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

DAY

 

 

YEAR

 

 

Other: _____________________________________

 

Classes which should be endorsed on

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qualified Without Restrictions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXAM CENTER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the Driver's PA License.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________ , _________

 

 

 

 

A

 

 

 

B

 

 

C

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PA DRIVER'S LICENSE NUMBER:

 

 

 

 

 

 

Former Driver's License #

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DL-180R (2-20) Individuals transferring a non-commerical driver's license, must be at least 16 1/2 years old.

Out-of-state licenses expired for more than 6 months cannot be transferred.

 

 

FEE INFORMATION

 

 

 

 

 

 

4-Year Photo

$30.50

* 4-Year Photo with Class M

$35.50

Drivers age 65 and over have the option of requesting a driver's license valid for two years instead of four. Fees for this option are:

 

2-Year Photo

$20.00

* 2-Year Photo with Class M

$25.00

If you would like to contribute to the Organ Donation Awareness Trust Fund, add an additional

$3.00

If you would like to make a tax deductible contribution to the Veterans' Trust Fund (VTF), add an additional

$3.00

* This additional fee is required by Act 31, 1984 and will be used to support the Motorcycle Safety Educational Program in the Commonwealth of Pennsylvania.

ORGAN DONATION AWARENESS TRUST FUND (ODTF): You have the opportunity to contribute $3.00 to the Fund. The additional $3.00 contribution must be added to your payment. You must also check the block provided to ensure proper handling of your contribution. The ODTF provides for the development and implementation of donor awareness programs and funds shall be appropriated subject to the approval of the Governor.

Veterans' Trust Fund (VTF): You have the opportunity to make a tax deductible contribution to the VTF. Your contribution will help support programs and projects for Pennsylvania veterans and their families. Since this additional $3.00 is not part of the fee, please add the donated amount to your payment. Also, please check the proper block on the form to ensure your contribution is handled properly.

You MUST appear in person at a Driver License Center and surrender your out-of-state license to apply.

Veterans Designation: You have the opportunity to add the veterans designation to your driver's license, which clearly indicates you are a veteran of the United States Armed Forces. To qualify, you must have served in the United States Armed Forces, including a reserve component or the National Guard, and have been discharged or released from such service under conditions other than dishonorable. If you are requesting to add the veterans designation to your license, make sure you check the box at the top in Section D.

No person shall receive a Pennsylvania Non-Commercial Driver's License unless and until the person surrenders to the Department all valid licenses in the person's possession issued by this or any other state.

Final approval of this application for a Pennsylvania Non-Commercial Driver's License is subject to verification of the applicant's past driver record history. Should verification disclose outstanding violations in any state or jurisdiction, the application will be denied and all issued Pennsylvania Driver's Licenses are subject to cancellation and recall.

It is unlawful for any person:

F To exhibit, cause a permit to be exhibited, or have in possession any recalled, cancelled, suspended, revoked, fictitious, or fraudulently altered driver's license. F To lend a driver's license to any other person or permit the use thereof by another.

F To exhibit or represent as one's own any driver's license not issued to the person.

F To fail or refuse to surrender to the Department upon lawful demand a recalled, cancelled, suspended, revoked, fictitious, or fraudulently altered driver's license.

PENALTIES AND SANCTIONS

Any persons violating any of the above is guilty of a summary offense and shall, upon conviction, be sentenced to pay a fine of $100. The Department may cancel any driver's license upon determining that the licensee was not entitled to the issuance or that the person failed to give the required or correct information or committed fraud in making the application or in obtaining the license or the fee has not been paid.

Any Pennsylvania driver who is convicted of any of the above offenses shall be assessed 3 points as of the date of violation.

A PERSON IS GUILTY OF A MISDEMEANOR OF THE FIRST DEGREE IF THE PERSON, WITH FRAUDULENT INTENT, HAS POSSESSION OF, SELLS OR ATTEMPTS TO SELL, USES OR DISPLAYS A DRIVER'S LICENSE, KNOWING IT TO HAVE BEEN ALTERED, FORGED OR COUNTERFEITED.

Any person committing this offense is, upon conviction, subject to imprisonment for a term of up to 5 years.

The Department shall revoke the driver's license privilege of any driver for one year upon receiving a certified record of the driver's conviction of this offense.

TO MEET IDENTIFICATION REQUIREMENTS YOU MUST PRESENT THE FOLLOWING

 

U.S. CITIZENS

NON-U.S. CITIZENS

 

Social Security Card (must be original; card cannot be laminated) and ONE of

You must bring ALL of the following:

 

the following:

• Original USCIS/immigration documents indicating current lawful immigration status

 

Birth Certificate with raised seal (U.S. issued by an authorized government

• Valid  Passport, dependent on status

 

 

agency, including U.S. territories or Puerto Rico. No other birth documents

• Social Security Card or SSA ineligibility letter (must be original; card cannot be laminated)

 

 

will be accepted.

(Please note: Documents must be original, photo copies will not be accepted.)

 

Certificate of U.S. Citizenship (BCIS/INS Form N-560)

 

 

 

Certificate of Naturalization (BCIS/INS Form N-550 or N-570)

To obtain detailed information regarding "identity/residency requirements," you can:

 

Valid U.S. Passport (Only valid U.S. Passports and original

 

• Visit www.dmv.pa.gov and Enter Search Term "Pub-195NC," and review required

 

 

documents will be accepted.)

 

 

documents; or

 

Note: Your Out-of-State Driver's License must be surrendered at the

• Contact us  at  717-412-5300. TTY callers - please dial 711 to reach us.

 

 

time you make application.

 

 

 

 

 

All documents must show the same name and date of birth, or an association between the information on the documents. Additional documentation may be

required, if a connection between documents cannot be established (e.g. Marriage Certificate, Court Order of name change, Divorce Decree, etc).

TO MEET RESIDENCY REQUIREMENTS YOU MUST PRESENT TWO OF THE FOLLOWING (for customers 18 years of age or older)

Current, unexpired PA driver’s license or photo ID card

PA vehicle registration card

Auto insurance card

A computer-generated utility bill showing your name and address (cellphone, cable, electric, gas)

Post-marked mail/package labels through USPS, UPS, FedEx etc.

A W-2 form/pay stub

Lease agreements or mortgage documents

Official Tax Records reflecting current name and address

--The proof of residency documents must have your name and official Pennsylvania street address on it.--

Note: If you reside with someone, and have no bills in your name, you will still need to provide two proofs of residency. One proof is to bring the person with whom you reside along with their Driver's License or Photo ID to the Driver License Center. You will also need to provide a second proof of residency such as post-marked mail/package labels through USPS, UPS, FedEx etc., that has your name and physical address on it. The address must match that of the person with whom you reside.

Change your address or renew your driver's license online at www.dmv.pa.gov

SECTION 3709 OF THE VEHICLE CODE

Section 3709 provides for a fine of up to $300 for dropping, throwing or depositing, upon any highway, or upon any other public or private property without the consent of the owner thereof or into or on the waters of this Commonwealth, from a vehicle, any waste paper, sweepings, ashes, household waste, glass, metal, refuse or rubbish or any dangerous or detrimental substance, or permitting any of the preceding without immediately removing such items or causing their removal.

For any violation of Section 3709, I may be subject to a fine of up to $300 upon conviction, including any violation resulting from the conduct of any other persons present within any vehicle of which I am the driver.

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In the THIS DEPARTMENT MAY REQUIRE A, If yes State DLLPID Name if, Is your right to apply for a, If yes give state date reason, Person in Loco Parentis or Spouse, HERE, XSIGN, signature of parent guardian, AUTHORIZATION AND CERTIFICATION, For Veterans wishing to add the, I acknowledge that receiving a, I am under the age of years and I, X APPLICANTS SIGNATURE IN INK, SIGN HERE, and DATE box, put down the information you have.

Finishing fillable pa form dl 180r step 2

Write any data you may need in the area Qualified with Restrictions, Uncorrected R, Corrected Right Eye Left Eye, SIGNATURE OF EXAMINER, DLE NO, DATE OF ISSUE, MONTH, DAY, YEAR, Classes which should be endorsed, EXAM CENTER, Former Drivers License State, and PA DRIVERS LICENSE NUMBER.

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