Form Dl 54A PDF Details

Form Dl 54A is an important document for businesses in California. This document is used to report information about a company's financial status. It is important to ensure that this form is filled out correctly and accurately, so that the state government can properly assess your business' finances. If you are unsure of how to complete Form Dl 54A, or if you have any other questions about it, please consult with a knowledgeable accountant or tax specialist. Failing to submit this form on time may result in penalties and fines from the state government. Thank you for your attention to this matter.

QuestionAnswer
Form NameForm Dl 54A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespa application identification card, pennsylvania identification card, pennsylvania dl application, form application identification form

Form Preview Example

 

DL-54A (7-21)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION FOR INITIAL IDENTIFICATION CARD

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL SECTIONS MUST BE COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JR./ETC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MIDDLE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

HEIGHT

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER OR DRIVER'S LICENSE 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINT NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male (M)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female (F)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-Binary/Other (X)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT STREET ADDRESS - A Post Office Box number may be used in addition to the actual residence address, but cannot be used as the only address.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE PA

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

If this is a change of address and you are a registered voter in PA, would you like us to

 

 

 

 

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

If you are not a registered voter, you may

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notify your county voter registration office of this change?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

contact your county voter registration office.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADD (Parental consent required if under 18)

 

 

REMOVE

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

Do you hold a current/valid out-of-state driver's license?

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

If yes, you must surrender your out-of-state valid license.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please provide the names and record

 

 

 

STATE

 

LP/DL/ID NUMBER

 

 

 

 

 

 

 

NAME (if different than above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

numbers (if known) of all States where you have

______

__________________________

 

____________________________________________________________________________

 

 

 

 

 

 

 

previously been issued a Learner Permit (LP),

______

__________________________

 

____________________________________________________________________________

 

 

 

 

 

 

 

Driver's License (DL), or Identification Card (ID).

______

__________________________

 

____________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

CHECK APPLICABLE BLOCK BELOW:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEE INFO.

 

 

 

1.

 

 

 

 

(You must apply in person at any Driver License Center.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$32.50

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I HAVE NEVER HELD A PA DRIVER'S LICENSE/PERMIT OR IDENTIFICATION CARD AND I AM APPLYING FOR AN INITIAL IDENTIFICATION CARD.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

I CURRENTLY HOLD A PA DRIVER'S LICENSE/PERMIT AND AM APPLYING FOR A NON-DRIVER IDENTIFICATION CARD FOR THE FOLLOWING REASON:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am surrendering my driving privilege for health reasons that may affect my ability to safely operate a motor vehicle. I understand that my license will not be

 

 

FREE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reissued until I successfully complete the appropriate examination. (If you have not already surrendered your Driver's License/ Learner's Permit,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

please attach it to this application.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am voluntarily surrendering my driving privilege with the understanding that it will be retained for a minimum of six months as required by 67 Pa. Code 93.2.

 

$32.50

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

It is understood that I will not be permitted to apply for my driver's license, Class A through M inclusive, for a period of six months. (Attach Driver's License/ Learner's

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permit.) A VOLUNTARY SURRENDER WILL NOT BE ACCEPTED TOWARD A SUSPENSION, RECALL, CANCELLATION, OR REVOCATION.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

As a result of my parent's or guardian's withdrawal of consent for me to drive a motor vehicle (Attach Driver's License/Learner's Permit.)

 

 

 

 

$32.50

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE NOTE: A DL-100A MUST ACCOMPANY THIS APPLICATION.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

As a result of the suspension of my driver's license. License MUST be attached. If not, you MUST complete the ACKNOWLEDGEMENT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I ___________________________________ hereby acknowledge that my driving privilege is suspended/revoked/disqualified in Pennsylvania and my

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

 

 

 

 

 

(PRINT NAME)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License issued by Pennsylvania has expired.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

 

 

License issued by Pennsylvania has been:

 

 

Lost

 

 

Stolen

 

 

 

Mutilated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$32.50

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When?______________________

How?

 

 

 

 

 

___________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

 

License issued by Pennsylvania has been surrendered to or confiscated by the Police/Court.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When?______________________

What Police Department/County?__________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

 

License issued by Pennsylvania has been previously surrendered to PennDOT to serve an existing period of suspension.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When?______________________

Why were you suspended?________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

I DESIRE TO HAVE AN IDENTIFICATION CARD ALONG WITH MY CURRENT/EXPIRED PA DRIVER'S LICENSE/PERMIT.

 

$32.50

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

CERTIFICATION (SIGN AND ENTER DATE OF APPLICATION)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUEST FOR ORGAN DONOR DESIGNATION

 

 

 

 

 

 

 

 

 

 

 

 

 

For Veterans wishing to add the Veterans Designation to their Driver's License or ID Card:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARENTAL CONSENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify under penalty of law that I am a qualified applicant and hereby request it be added to my

 

 

 

 

 

 

I am under the age of 18 years and I hereby request Organ Donor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

product. I understand that misrepresentation will result in the cancellation of my identification card.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

designation on my Pennsylvania I.D. Card. Applicants 18 years of age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I acknowledge that receiving a Pennsylvania Permit, License or ID card will cancel or invalidate any Permit,

 

 

 

 

or older will have the opportunity to request Organ Donor designation

 

 

 

License or ID card from another state. I certify under penalty of law that all information given on this

 

 

 

 

on my Pennsylvania I.D. Card.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

application is true and correct. I hereby authorize the Social Security Administration to release to the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that I am a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department of Transportation information concerning my Social Security Identification Number for the

 

 

 

 

 

 

Parent,

 

 

Guardian,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

purpose of identification. If using a Messenger Service, I hereby authorize the Department to furnish

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person in Loco Parentis, or

 

Spouse at least 18 years of age and

 

 

 

 

 

 

 

 

 

 

 

 

 

them with my driving record for the purpose of processing this form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

I:

 

 

 

Do give consent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do NOT give consent for applicant's request for Organ

 

 

 

 

 

 

 

 

 

 

SIGN

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Donor designation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEREX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT'S SIGNATURE IN INK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

HEREX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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, Section 4904 [b]).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF PARENT, GUARDIAN, PERSONS IN LOCO PARENTIS, OR SPOUSE AT LEAST 18 YEARS OF AGE

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAID BY:

 

Debit/Credit Card

 

Check

Money Order Payable to PennDOT (PennDOT Driver License Centers do not accept cash.)

 

TOTAL $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

DEPARTMENTAL USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID NUMBER ______________________________________________

 

 

 

RESIDENCY REQUIREMENTS (LIST TWO) 1. ________________________________________ 2. _________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VERIFICATION OF BIRTH DATE & IDENTITY

 

Birth certificate

 

 

 

Other _________________________________________________________

 

 

 

 

 

SIGN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEREX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF EXAMINER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BADGE NO.

 

 

 

 

 

 

 

 

 

EXAM CENTER

 

 

 

 

 

 

 

 

 

 

 

 

 

DL-54A (7-21)

You must be at least 10 years of age or older to obtain a Pennsylvania Identification Card.

If you are under 18 years of age your parent, guardian, person in loco parentis, or spouse who is 18 years of age or older must accompany you. Proper Identification is required and if the last names are different, verification of relationship is needed.

Out-of-State Address Change: We may not issue driver license products to an out-of-state address, except in the case of an

employee of the federal or state government, armed forces personnel, and immediate members of their families, whose workplace is located outside of Pennsylvania. If this exception applies to you, please check the appropriate box and include documentation of your status with this application. Attach a letter from your employer on their letterhead to document your status, or attach a copy of your current Photo ID issued by your employer. If you are the immediate family of a person meeting one of the allowable exceptions,

attach the documentation of the person employed. Additionally, you must indicate your relationship to that person.

I certify that my workplace is located out-of-state and I am employed by, or am the immediate family of a person employed by:

 

 

US Armed Forces

 

Federal Government

 

Pennsylvania State Government

Relationship to person meeting exemption (check one):

 

Spouse

 

Dependent Child

 

 

 

 

SECTION C

If you check block 1, you must apply in person at a Driver License Center with the identity and residency documents listed below. If you check block 2 or block 3, you can mail your completed and signed application.

SECTION D

Veterans Designation: You have the opportunity to add the veterans designation to your identification card, 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 ID card, make sure you check the box at the top in Section D.

NOTE: Driver License Centers do not accept cash.

If mailing your application along with your check or money order (if applicable) made payable to PennDOT, send to the: Bureau of Driver Licensing, P.O. Box 68272, Harrisburg, PA 17106-8272.

TO MEET IDENTIFICATION REQUIREMENTS You MUST Present the Following:

U.S. CITIZENS - You must bring the Original Social Security Card (card cannot be laminated) AND ONE of the following:

• Birth Certificate with raised seal (U.S. issued by an authorized government agency, including U.S. territories or Puerto Rico. Non-U.S. Birth Certificates will not be accepted.) No other birth documents will be accepted.

• Certificate of U.S. Citizenship (USCIS Form N-560)

• Certificate of Naturalization (USCIS Form N-550 or N-570)

• Valid U.S. Passport (Only valid U.S. Passports and original documents will be accepted.)

✦If you have an Out-of-State Driver's License, it must be presented with one of the above forms of identification.

NOTE: If the name on your original document differs from your current name, you must provide an original Marriage Certificate, Divorce Decree, or Court Order document.

NON-U.S. CITIZENS - You must bring all of the following:

•Original USCIS/immigration documents indicating current lawful immigration status

•Valid Passport, dependent on status

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

(Please note: Documents must be original, photo copies will not be accepted.) To obtain detailed information regarding "identity/residency requirements," you can:

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

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

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 address on it. The address must match that of the person with whom you reside.

Organ Donor 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.

The department is required to obtain the Licensee's Social Security number, height and eye color under the provisions of Sections 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.

Visit us at www.dmv.pa.gov or call us at 717-412-5300. TTY callers -- please dial 711 to reach us

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2. Once your current task is complete, take the next step – fill out all of these fields - I am surrendering my driving, License issued by Pennsylvania has, PRINT NAME, I DESIRE TO HAVE AN IDENTIFICATION, FREE, CERTIFICATION SIGN AND ENTER DATE, For Veterans wishing to add the, I wish to contribute to the Organ, HERE, XSIGN WARNING Misstatement of Fact, APPLICANTS SIGNATURE IN INK, DATE, REQUEST FOR ORGAN DONOR DESIGNATION, PARENTAL CONSENT, and I am under the age of years and I with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

REQUEST FOR ORGAN DONOR DESIGNATION, I wish to contribute to the Organ, and For Veterans wishing to add the in pennsylvania identification card get

3. This next step is going to be easy - fill out all the fields in XSIGN WARNING Misstatement of Fact, Do NOT give consent for applicants, HERE, SIGNATURE OF PARENT GUARDIAN, DATE, PAID BY DebitCredit Card Check, Payable to PennDOT PennDOT Driver, TOTAL, DEPARTMENTAL USE ONLY, ID NUMBER, RESIDENCY REQUIREMENTS LIST TWO, XSIGN, HERE, SIGNATURE OF EXAMINER, and DATE to conclude this segment.

pennsylvania identification card get conclusion process clarified (portion 3)

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