Pa Driver'S License Physical Form Details

Form Dl 180 is an important form that must be filed with the California Secretary of State's office within 10 days of making a contribution in excess of $1,000 to any political committee or other entity required to file reports with the Secretary of State. This form must be completed by the individual or organization making the contribution. The purpose of this form is to disclose the identities of all donors who contribute more than $1,000 to a political committee or other entity during a calendar year. By law, all contributions over $1,000 must be reported, regardless of whether they are monetary or in-kind donations. Penalties may be assessed for late filing or failure to report contributions.

This information will aid you to comprehend better the details of the form dl 180 before you start filling it out.

QuestionAnswer
Form NameForm Dl 180
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesdl180 form, penndot physical form, pennsylvania permit application, dl 180

Form Preview Example

DL-180 (12-18)

NON-COMMERCIAL LEARNER'S PERMIT APPLICATION

YOU MUST APPLY IN PERSON

THIS FORM IS VALID FOR 1 YEAR FROM THE DATE OF PHYSICAL EXAMINATION

DRIVER'S LICENSE

 

 

 

 

 

 

The physical date may not be more than 6 months prior to your 16th birthday.

NUMBER/I.D. NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME (S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JR./ETC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MIDDLE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

HEIGHT

 

 

 

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

SEX

 

 

TELEPHONE NUMBER

 

 

 

 

EMAIL ADDRESS

MONTH

DAY

YEAR

FEET

 

 

 

 

INCHES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EYE COLOR (Please check one):

 

 

 

 

BLUE

 

 

 

BROWN

 

 

 

GREEN

 

 

 

 

HAZEL

 

 

 

PINK

 

 

 

 

BLACK

 

 

GRAY

 

 

DICHROMATIC

 

 

 

OTHER ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS - A Post Office Box number may be used only in addition to the actual street address.

CITY

 

 

 

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERMIT(S) DESIRED

 

 

 

 

 

 

 

 

 

FEE

 

ENTER FEE FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EACH ITEM CHECKED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESIRED

 

CLASS A (Combination Vehicle over 26,000),     CLASS B (Truck or Bus over 26,000) OR   CLASS C (Automobile)

$5.00

 

 

 

PERMIT(S)

 

 

 

 

 

  CLASS M (Motorcycle) MSEA Fee is included

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$15.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE REQUIRED

 

 

 

 

 

 

 

 

&

 

ENTER FEE FOR

MUST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE CHECKED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4-Year Driver's License

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$30.50

 

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2-Year Driver's License (Age 65 & Over)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$20.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trust Fund Contribution(s) - If you wish to contribute to the Organ Donation Awareness Trust Fund (ODTF) and/or the Veterans' Trust Fund (VTF)

 

 

ENTER FEE FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

check the appropriate box(s) and enter total amount to the right. (see reverse)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTRIBUTION(S) HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$1.00 to the Organ Donation Trust Fund (ODTF) 

 

 

$3.00 to the Veterans' Trust Fund (VTF)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAID BY:

Check

Money Order

Payable to PennDOT (Cash, Credit, or Debit Card CANNOT be accepted)

TOTAL

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL QUESTIONS MUST BE ANSWERED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check [4] Applicable Block) YES NO

1.

Have you ever held or possessed a Driver's License (DL)/Learner's Permit (LP)/Photo Identification Card (ID) from PA or 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: __________________________________________________________________

2.

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

 

 

 

 

 

 

 

or subject to installation of an ignition interlock device?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, give state 

 

 

 

 

 

 

date

 

 

 

 

 

 

,  and reason

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

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

 

 

 

 

 

 

 

,  and reason 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Do you hold a valid license or ID card from any other state?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATIONS AND CERTIFICATIONS

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  am  under  the  age  of  18  years  and  I  hereby  request  Organ  Donor  designation  on  my  PA  Driver’s  License.  Parent  must  check  consent  block  on  the  ParenGuardian  Consent  Form  (DL-180TD). (Applicants 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.)

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 this 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. 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]).

XSIGN HERE

(APPLICANT'S SIGNATURE IN INK)

(DATE)

DL-180 (12-18)

FOR OFFICIAL USE ONLY

ALL INFORMATION IN THIS SECTION MUST BE COMPLETED IN FULL BY A HEALTH CARE PROVIDER

Please check any of the following that WOULD prevent control of a motor vehicle.

Neurological disorders  Uncontrolled Epilepsy 

Neuropsychiatric disorders 

Uncontrolled Diabetes 

Circulatory disorder 

Cognitive Impairment

Cardiac disorder 

Alcohol abuse

Hypertension

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.

VISION SCREENINGCHECK (3 ) YES NO

20/40 vision or less in better eye with correction.........................................

Report of Eye Examination (attached).....................................................

Qualified Without Restrictions

Qualified With Restrictions

 

Corrective Lenses

Other: ______________________________________________

COMPLETE ALL ITEMS

Uncorrected

 

Corrected

 

 

 

 

 

20/

 

Right Eye

20/

 

20/

 

Left Eye

20/

 

20/

 

Both Eyes

20/

 

R

L

Fields

R

L

 

 

 

 

 

PROVIDER INFORMATION (Please print or type)

PROVIDER'S NAME 

SPECIALTY 

STATE LICENSE #

STREET ADDRESS 

CITY 

STATE  ZIP CODE

TELEPHONE 

     FAX 

I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements made herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities) punishable by  a fine up to $2,500 and/or imprisonment up to 1 year.

 Examinee's Signature (SIGN ONLY IN PRESENCE OF PROVIDER)                    Provider's Signature                                                 Physical Date

COMPLETED BY DRIVER LICENSE EXAMINER ONLY

EXAMINER'S DRIVER CERTIFICATION

This is to certify that the above applicant has applied for and passed the examination for the above class(es) for a Pennsylvania Driver's License.

DATE OF ISSUE:

MONTH

DAY

YEAR

EXAM CENTER:

 

 

 

 

(SIGNATURE OF EXAMINER) 

 

                 (DLE NO.)

 

 

 

 

 

 

 

 

 

 

TO MEET IDENTIFICATION REQUIREMENTS YOU MUST PRESENT THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizens -

Non-U.S. Citizens – You must bring ALL of the following:

 

 

 

 

 

Social Security Card (must be original; card cannot be

• Original USCIS/immigration documents indicating current lawful

 

laminated) AND ONE of the following:

 

immigration status

 

 

 

 

 

• Birth Certificate with raised seal (U.S. issued by an autho-

• Valid  Passport, dependent on status

 

 

 

 

 

rized government agency, including U.S. territories or Puerto

• Social Security Card or SSA ineligibility letter (must be original; card

 

Rico.) No other birth documents will be accepted.

 

cannot be laminated)

 

 

 

 

 

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

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

 

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

 

accepted.)

 

 

 

 

 

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

To obtain detailed information regarding "identity/residency

 

documents will be accepted.)

requirements," you  can:

 

 

 

 

 

NOTE: If you have an Out-of-State Driver's License, you should

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

 

 

review required documents; or  

 

 

 

 

 

present it along with your Social Security Card and one of

 

 

 

 

 

 

the above forms.

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.)

DL-180 (12-18)

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

Tax Records     •  Lease Agreements     •  Mortgage Documents     •  W-2 Form

Current Weapons Permit (U.S. Citizen only)      •  Current Utility Bills (water, gas, electric, cable, etc.)

--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 official mail (bank statement, tax notice, magazine etc.) that has your name and physical address on it. The address must match that of the person with whom   you reside.

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 condi- tions other than dishonorable. If you are requesting to add the veterans designation to your license, make sure you check the box at the top of the Authorization and Certification Section on side 1.

ORGAN DONATION AWARENESS TRUST FUND (ODTF): You have the opportunity to contribute $1.00 to the Fund. The additional $1.00 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.

Permit Fee: Additional permit fee of $5.00 for each class permit requested.

MSEA Fee: These additional fees are required under the Pennsylvania Vehicle Code Section 7904 and will be used to

support a Motorcycle Safety Education Program in the Commonwealth of Pennsylvania.

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.

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