Form Dl 80 Pennsylvania PDF Details

This week the Pennsylvania Department of State released a new form, Dl 80, which businesses must use to apply for registration as a foreign corporation doing business in Pennsylvania. The form is available on the department's website and must be filled out and submitted online. The department has also released a guide to help fill out the form. The guide provides detailed information about each section of the form and how to complete it. Penalties may be imposed for businesses that submit inaccurate or incomplete information on the form. So far, over 1,500 businesses have registered using Dl 80.

QuestionAnswer
Form NameForm Dl 80 Pennsylvania
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdrivers license application, Notarization, driver license application, pa driver's license form

Form Preview Example

DL-80 (3-11)

NON-COMMERCIAL DRIVER’S LICENSE

APPLICATION FOR CHANGE / CORRECTION / REPLACEMENT PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION

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

CHECK APPLICABLE BLOCK:

PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE.

REPLACEMENT (DUPLICATE) – Complete Sections A, B, (C & D if applicable),

CHANGE OR CORRECTION of Non-Commercial License.

E and F. All requests marked with an asterisk (*) MUST be notarized.

Complete Section A, C and F. Notarization is not required.

Complete absence statement on reverse side if applicable.

An update card will be issued.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A YOU 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)

 

ORGAN DONOR

 

 

 

*REGULAR CAMERA CARD

 

 

PHOTO LICENSE

 

UPDATE CARD

 

 

LOST

 

 

MUTILATED

 

 

DESIGNATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOLEN

 

 

CORRECTION

 

 

ADD (parental consent in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*“PHOTO-EXEMPT’’ CAMERA CARD

 

VALID W/O PHOTO LICENSE

 

 

*NEVER RECEIVED

 

 

OTHER ______________________

 

 

 

Section D required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

if under 18)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(STATEMENT ON REVERSE MUST BE COMPLETED AND SIGNED)

 

 

(No Fee Required)

_____________________________

 

 

REMOVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CCHANGE OR CORRECTION ONLY (Important information on reverse side)

ADDRESS CHANGE -A Post Ofice 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME CHANGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER (see reverse side)

 

 

 

 

 

 

 

 

 

 

 

REASON:

 

 

MARRIAGE

 

 

DIVORCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JR., ETC.

FIRST NAME

 

 

 

 

 

 

 

 

MIDDLE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER CHANGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EYE COLOR (Please check one):

 

BLUE

 

BROWN

GREEN

 

HAZEL

PINK

BLACK

GRAY

DICHROMATIC

OTHER ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CORRECTION OF DATE OF BIRTH

 

HEIGHT

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

DROP PRIVILEGE

 

 

 

 

MONTH

 

 

 

DAY

 

 

 

 

 

 

 

 

YEAR

 

FEET

INCHES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DROP CLASS M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSENT OF PARENT, GUARDIAN, PERSON IN LOCO PARENTIS OR SPOUSE AT LEAST 18 YEARS OF AGE. Complete if

D 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 a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent,

 

 

 

Guardian,

 

 

 

 

Person in Loco Parentis

 

Spouse at least 18 years of age and I:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do give consent

 

 

 

Do not give consent for applicant’s request for Organ Donor Designation.

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 IF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

YES

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPLACEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

YES

 

 

NO - Have you been arrested or cited in this state or any other state for any violation which carries a possible penalty of suspension or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS REQUESTED

 

 

 

 

 

 

 

 

 

 

 

 

revocation of your driver’s license or driving privilege?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, give state_________ Date ______________ and Reason ___________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAUTHORIZATION AND CERTIFICATION

I certify under penalty of law that all information given on this application is true and correct. I hereby

 

 

AFFIDAVIT: This section must be notarized when applying for replacement of a

authorize the Social Security Administration to release to the Department of Transportation information

 

 

Camera Card. You are entitled to a free replacement ONLY if this application is

concerning my Social Security Identication Number for the purpose of identication. If using a Messenger

 

 

completed within 90 days of the original date of issuance and the original was

Service, I hereby authorize the Department to furnish them with my driving record for the purpose of

 

 

never received due to loss in the mail.

 

 

 

processing this form. I hereby acknowledge this day that I have received notice of the provisions of Section

 

 

 

 

 

 

 

 

 

 

SUBSCRIBED AND SWORN

 

 

 

3709 of the Vehicle Code. (See reverse for provisions.)

 

 

 

 

 

 

 

 

 

 

 

 

 

FEE PAID

 

 

 

TO BEFORE ME:

MO.

DAY

YEAR

 

 

 

 

I wish to contribute $1.00 to the Organ Donation

 

SEND CHECK

 

 

 

 

 

 

 

 

IN THIS

 

 

 

 

 

Signature of Person Administering Oath

 

 

 

 

 

Awareness Trust Fund (see reverse).

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE REVERSE FOR FEES

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WARNING: Misstatement of fact is

 

 

 

 

 

 

SIGN

 

 

 

E

 

SIGN IN PRESENCE OF NOTARY

 

 

 

 

a misdemeanor of the third degree

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE

 

punishable by a ine of up to $2,500

 

 

A

 

 

 

 

 

 

X

 

and/or imprisonment up to 1 year

 

 

L

 

 

 

 

 

 

 

 

 

 

(18 PA C.S. Section 4904(b)).

 

 

 

 

 

 

 

 

 

 

(APPLICANT’S SIGNATURE IN INK)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DL-80 (3-11)

For More Drivers License Information - http://pa-license.com

APPLICANT INFORMATION

•Photo Exemption: Complete form as indicated. Sign both Section ‘’F’’ and the statement below. PennDOT will send you a camera card and further instructions.

During the next 60 days I will be absent from PA for the following reason:

 

Military

 

School

 

Work

 

Travel

Within 45 days of my return I will apply for a driver’s license containing my photo.

XSIGN

HERE

SIGNATURE HERE

•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

 

 

•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.

•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 ind 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 MUST

NON-COMMERCIAL:

BE NOTARIZED IN SECTION F.

 

 

PHOTO OR VALID W/O

FEE: $13.50 - 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

PHOTO NON-COMMERCIAL

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

DRIVER’S LICENSE

If license is endorsed with Class M, fee is $18.50.

 

*REGULAR OR “PHOTO

FEE: $5.00 if photo was not taken with the original camera card.

EXEMPT” CAMERA CARD

If license is endorsed with a Class M, fee is $10.00.

 

 

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, the form must be notarized and a

DESIGNATION

replacement fee is required. Refer to fees above.

ORGAN DONATION

You have the opportunity to contribute $1.00 to the Fund. The additional $1.00 contribution must be added to

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

AWARENESS TRUST FUND

in Section F to ensure proper handling of your contribution.

(ODTF)

 

 

 

CHANGE/CORRECTION

ONLY

NO FEE REQUIRED — The Bureau will issue an update card relecting the change/correction which must be carried with the driver’s license. Notarization is not required.

NAME CHANGE - If your name changed by permission of court, attach a Certiied Copy of the Court Order. If you desire to use a name other than your

(1) birth name, (2) spouse’s surname, or (3) a name given through a Court Order, you must provide a copy of your Social Security Card (or records), together with copies of documents from 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, or state issued Birth Certiicate.

IF YEAR OF BIRTH on driver’s license is incorrect, attach a copy of your oficial birth certiicate.

IF Social Security Number is incorrect, attach copy of your Social Security Card.

PROVISIONS OF SECTION 3709 OF THE VEHICLE CODE

Section 3709 provides for a ine 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 ine 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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Part no. 1 in filling in PennDOT

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Stage no. 2 of submitting PennDOT

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4. This next section requires some additional information. Ensure you complete all the necessary fields - Photo Exemption Complete form as, During the next days I will be, HERE, SIGNATURE HERE, of the federal or state government, OUTOFSTATE ADDRESS CHANGE We may, I certify that my workplace is, Relationship to person meeting, Return your completed and signed, Harrisburg PA If your license is, and REPLACEMENT OF NONCOMMERCIAL - to proceed further in your process!

Harrisburg PA If your license is, OUTOFSTATE ADDRESS CHANGE We may, and I certify that my workplace is of PennDOT

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