Dl 80 Form PDF Details

Dl 80 form is a document that is used in the business world to provide important information about a company or individual. The document is used to provide essential details such as the name of the company or individual, their contact information, and what the company or individual does. This document can be used for a variety of purposes, such as when applying for a loan or when setting up a meeting with a potential client. By having this document on hand, you will make an excellent first impression and show that you are organized and professional.

Before you fill in dl 80 form, you'll want to know more in regards to the type of form you'll work with.

QuestionAnswer
Form NameDl 80 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesget the dl 80 form, dl80, pa dl 80, dl 80 form online

Form Preview Example

DL-80 (12-21)

NON-COMMERCIAL DRIVER’S LICENSE

APPLICATION FOR CHANGE / CORRECTION / REPLACEMENT

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

CHECK APPLICABLE BLOCK:

REPLACEMENT (DUPLICATE) – Complete Sections A, B, (C & D if applicable), E and F. All requests marked with an asterisk (*) MUST be notarized. Complete absence statement on reverse side if applicable.

CHANGE OR CORRECTION of Non-Commercial License. Complete Section A, C and F. Notarization is not required. An update card will be issued.

AYOU MUST COMPLETE ALL PARTS OF SECTION A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S LICENSE NUMBER

 

 

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JR./ETC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MIDDLE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

OF BIRTH

 

 

 

 

 

 

TELEPHONE NUMBER (8:00A.M. - 4:30P.M.)

 

 

 

 

 

E-MAIL ADDRESS (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

DAY

 

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

APPLICATION FOR REPLACEMENT (CHECK ONE)

 

 

 

 

 

 

 

 

 

 

 

 

REPLACEMENT REQUIRED DUE TO REASON (CHECK ONE)

 

 

 

*REGULAR CAMERA CARD

 

 

 

PHOTO LICENSE

 

 

UPDATE CARD

 

 

 

 

 

 

 

LOST

 

 

MUTILATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOLEN

 

 

CORRECTION

 

 

 

*“PHOTO-EXEMPT’’ CAMERA CARD

 

 

 

VALID W/O PHOTO LICENSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*NEVER RECEIVED

 

 

OTHER ______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(DL-82 MUST BE COMPLETED AND SUBMITTED ALONG WITH THIS FORM)

 

 

 

 

 

 

 

(No Fee Required)

 

 

_____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pennsylvania strongly supports organ and tissue donation because of its life-saving and life-enhancing opportunities.

ORGAN DONOR DESIGNATION:  

 

 

 

REMOVE

    ADD (Parental consent in Section D required if under 18)

 

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

CITY

STATE PA ZIP CODE

This application will also serve as a request to update your voter registration unless you check this box:

If you are not registered to vote, you will receive an application to register. You must be a U.S. citizen to register to vote in Pennsylvania.

NAME CHANGE (Please note all name changes must be done in person with original documents) REASON:   MARRIAGE   DIVORCE   OTHER (see reverse side)

LAST

JR., ETC. FIRST NAME

MIDDLE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER CHANGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BLUE 

 

 

 

 

 

BROWN   

 

 

GREEN 

 

 

HAZEL   

 

 

 

 

 

 

 

BLACK   

 

GRAY 

 

 

  DICHROMATIC   

 

  OTHER________________

 

 

EYE COLOR (Please check one):    

 

 

 

 

 

 

  PINK   

   

   

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADD LENS RESTRICTION

 

 

OR

 

 

 

 

 

REMOVE LENS RESTRICTION - (Please Note: Must include DL-102 Application completed by Health Care Provider)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CORRECTION OF DATE OF BIRTH

 

 

 

 

 

 

HEIGHT

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

 

DROP PRIVILEGE

 

 

 

MONTH

 

DAY

 

 

 

 

 

 

 

 

YEAR

 

 

 

 

 

FEET

 

 

INCHES

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

DROP CLASS M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

 

CONSENT 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 to give consent for Applicant’s request for Organ Donor Designation.

 

 

 

 

 

 

 

 

 

I hereby certify that I am

 

 

 

 

Parent,

 

 

 

 

 

Guardian,

 

 

Person in Loco Parentis or

 

 

Spouse

 

 

SIGN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

at least 18 years of age, of the applicant named herein, that the statements made herein are true and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

(SIGNATURE OF PARENT, ETC.)

E

ALL MUST BE

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

 

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

 

 

 

ANSWERED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

YES

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

IF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

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 of

 

 

REPLACEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS REQUESTED

If yes, give state_________ Date ______________ and Reason ___________________________________________________________

FAUTHORIZATION 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

AFFIDAVIT: This section must be notarized when applying

 

 

 

 

 

a qualified applicant and hereby request it be added to my product. I understand that misrepresentation will result in the cancellation of

for replacement of a Camera Card. You are entitled to a free

 

 

 

 

my driver’s license.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

replacement ONLY if this application is completed within 90

 

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

 

days of the original date of issuance and the original was

 

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

 

never received due to loss in the mail.

 

release to the Department of Transportation information concerning my Social Security Identication Number for the purpose of identication. 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.)

 

SUBSCRIBEDAND SWORN TO BEFORE ME:

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO.

DAY

YEAR

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Person Administering Oath

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(APPLICANT’S SIGNATURE IN INK)

 

 

 

DATE

 

 

E

 

SIGN IN PRESENCE OF NOTARY

 

 

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)).

 

A

 

 

PAID BY:

 

Debit/Credit Card

 

Check

Money

License Centers do not accept cash.)

TOTAL $

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

Order

Payable to PennDOT (PennDOT Driver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DL-80 (12-21)

The most current version of this form can be found at: www.dmv.pa.gov

•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/ID card, make sure you check the box at the top in Section F.

•Return your completed and signed application with check or money order made payable to “PennDOT”, to: Bureau of Driver Licensing, P.O. Box 68272, Harrisburg, PA 17106-8272.

•Out-of-State Address/Photo Exemption - If requesting an out of state address or photo exemption you must complete an Out-Of-State Address/ Photo Exemption Form (DL-82) and submit along with this form. NOTE: For Photo Exemption, you must be out of state for the entire next 60 days.

•If your license is due to expire within six (6) months, DO NOT use this form. Complete form DL-143 (Renewal of a Non-Commercial Driver’s License).

•If you find or recover your original license after you have submitted this application for a duplicate, return the original license with a letter of explanation to: Bureau of Driver Licensing, P.O. Box 68615, Harrisburg, PA 17106-8615. After duplicate is issued, the original license is no longer valid.

 

REPLACEMENT OF

Application for replacement of a camera card or a product never received, the form must be notarized.

 

NON-COMMERCIAL

 

 

 

 

PHOTO OR VALID W/O

FEE: $31.50 - The Bureau will issue a camera card, which is a temporary Non-Commercial Driver’s License

 

valid for 60 days. During those 60 days, the driver must appear at a photo driver license center for the purpose

 

PHOTO NON-COMMERCIAL

 

of having a photo taken. If photo image is on file, the Bureau will issue a Photo Driver’s License. If license is

 

DRIVER’S LICENSE

 

endorsed with Class M, fee is $36.50.

 

 

 

*REGULAR OR “PHOTO

FEE: $5.00 if photo was not taken with the original camera card and this form must be notarized.

 

EXEMPT” CAMERA CARD

If license is endorsed with a Class M, fee is $10.00 and this form must be notarized.

 

UPDATE CARD

No Fee. (update cards are not issued if requesting a change of Organ Donor designation status)

 

ORGAN DONOR

When you are adding or removing the Organ Donor designation a replacement fee is required. Refer to fees

 

DESIGNATION

above.

 

ORGAN DONATION

You have the opportunity to contribute $3.00 to the Fund. The additional $3.00 contribution must be added to

 

AWARENESS TRUST FUND

the fees above and included in your payment by check/money order. You must also check the block provided

 

(ODTF)

in Section F to ensure proper handling of your contribution.

 

VETERANS DESIGNATION

When you are adding or removing the Veterans designation a replacement fee is required. Refer to fees

 

above.

 

 

 

 

VETERANS’ TRUST

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

 

FUND (VTF)

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.

CHANGE/CORRECTION

ONLY

NO FEE REQUIRED — The Bureau will issue an update card reflecting the change/correction which must

be carried with the driver’s license. Notarization is not required.

NAME CHANGE - If you desire to use your birth name, you must present your state issued birth certificate with a raised seal. If your name changed by permission of court, you must present a Certified Copy of the Court Order. If you desire to use your spouse’s surname, you must present your marriage certificate. If you desire to use another name, you must present your Social Security Card, together with two other sources issued in the desired name such as: Tax Records, Selective Service Card, Voter Registration Card, Passport, any form of Photo I.D. issued by a governmental agency, banking records, or baptismal certificate.

To report errors on your driver’s license relating to name, date of birth or social security number, please contact PennDOT’s Customer Care Center at 717-412-5300. TTY callers - please dial 711 to reach us.

If you are required to present supporting documentation to correct your record, all documents must be originals and presented in person at a PennDOT Driver License Center.

·For NAME corrections, you must present your state issued birth certificate with a raised seal, a Certified Copy of the Court Order or your marriage certificate.

·For DATE OF BIRTH corrections, you must present state issued birth certificate with raised seal.

·For SOCIAL SECURITY NUMBER corrections, you must present your Social Security Card.

*Note: All name changes must be made in person at a Driver License Center. All documents must be original.

GENDER CHANGE - If requesting a gender change, a DL-32 (Request for Gender Designation Change) application must be completed along with this application and submitted in person to a Driver License Center for processing.

PROVISIONS OF 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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Note the appropriate data in the segment ADD LENS RESTRICTION OR REMOVE, CORRECTION OF DATE OF BIRTH, HEIGHT, MONTH, DAY, YEAR, FEET, INCHES, SOCIAL SECURITY NUMBER, DROP PRIVILEGE, DROP CLASS M, CONSENT OF PARENT GUARDIAN PERSON, I hereby certify that I am Parent, at least years of age of the, and correct to the best of my.

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