Pa Dl 901 Form – Fill Out and Use This PDF

DL-901 (5-13)

MUST CHECK ONE:

DRIVER'S LICENSE

LEARNER'S PERMIT

IDENTIFICATION CARD

A

YOU MUST COMPLETE ALL PARTS OF SECTION A

LICENSE/PERMIT/ID 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

REASON

( * must be notarized)

PRODUCT NEEDED

ORGAN DONOR

ADD/EXTEND

RENEW

STOLEN

MUTILATED

*CAMERA CARD (notarization not required if renewing)

DESIGNATION

ADD

LICENSE/ID CARD

LEARNER'S PERMIT

UPDATE CARD

LOST

CHANGE/CORRECT

* NEVER RECEIVED

DO NOT ADD

MOTORCYCLE (license only renewal) NOTE: Class M information see reverse

OTHER

REMOVE

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.

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

REASON:

MARRIAGE

DIVORCE

OTHER (see reverse side)

LAST NAME

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

D* MUST BE COMPLETED IF APPLICANT IS UNDER THE AGE OF 18 APPLYING FOR A LEARNER'S PERMIT OR ORGAN DONOR DESIGNATION

I hereby certify that I am a

Parent,

Guardian,

Person in Loco Parentis, or

Spouse at least 18 years of age, of the applicant

named herein, that the statements made hereon are true and correct to the best of my knowledge and that this application is made with

my full consent.

X

SIGN

HERE

(SIGNATURE OF PARENT, GUARDIAN, Person in Loco Parentis, or Spouse at least 18 years of age.)

E

FOR

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

DRIVER'S

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

1.

YES

NO - Do you hold a valid driver's license issued by any other state?

LICENSE

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

AND

2.

YES

3.

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

LEARNER'S

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

PERMIT

If yes to any question, give state _______ Date ____________ and Reason _________________________________________________________

F

AUTHORIZATION AND CERTIFICATION

G

NOTARY (see instructions on back)

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

SUBSCRIBED AND SWORN

correct. I hereby authorize the Social Security Administration to release to the Department

of Transportation information concerning my Social Security Identification Number for the

TO BEFORE ME:

MO.

DAY

YEAR

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

SIGNATURE OF PERSON ADMINISTERING OATH

acknowledge this day that I have received notice of the provisions of Section 3709 of the

Vehicle Code. (See reverse for provisions.)

FEE

SIGN

SEE REVERSE FOR FEES

S

XHERE

E

WARNING: Misstatement of fact

is a misdemeanor of the third

SIGN IN PRESENCE OF NOTARY

Applicant's Signature in Ink

(Date)

degree punishable of up to $2,500

A

and/or imprisonment up to 1 year

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

L

I wish to contribute $1.00 to the Organ Donation Awareness Trust Fund (see reverse).

DL-901 (5-13)

Change your address or renew your Non-Commercial Driver's License online at www.dmv.state.pa.us

The most current version of this form can be found on our website.

INSTRUCTIONS

1.All applicants must complete Sections A, B, (C & D if applicable), E, F. Section G must be completed if applying for a product marked with an asterisk (*) in section B or if section D is completed.

2.Section D MUST be completed if applicant is under the age of 18.

3.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.

4.If you have not taken or successfully completed the Road Test within three (3) years of your physical examination date, you MUST start over with another Non-Commercial Learner's Permit Application and retake the Knowledge Test.

NOTE: 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.

NOTARY

This form must be notarized if: 1. Requesting a product that was never received, 2. Requesting a camera card (notorization not required if renewing), 3.

You are under 18 years of age applying for a learner's permit or organ donor designation. The notarization section must be signed in the presence of a notary or Driver License Examiner. NOTE: If you are requesting a camera card due to renewing, this form does not need to be notarized.

FEE INFORMATION

-You are entitled to a free replacement ONLY if this application is completed within 90 days of the original date of issuance and the original was never received due to loss in the mail.

-The fee for a Class A, B, or C non-commercial Learner's Permit is $5.00 for each permit requested. If you checked the never received box in section

B (form must be notarized), a fee is not required if within 90 days of issuance.

-If requesting an update card, a fee is not required.

RENEWAL LICENSES		DUPLICATE		LEARNER'S PERMITS
Renew 4-Year License	$29.50	Duplicate Camera Card (License or I.D.)	...$5.00	Add/Extend/Replace Non-Commercial
Renew 4-Year License w/Class M	$49.50	Duplicate Camera Card w/Class M	$10.00	Class A, B, or C Permit	$5.00
Renew 2-Year License (age 65+)	$19.00	Duplicate License/I.D	$13.50	IDENTIFICATION CARDS
Renew 2-Year License w/Class M (age 65+)..	$29.00	Duplicate License w/Class M ......$18.50		Renew/Replace	$13.50

NOTE: Update Cards, No Fee. (update cards are not issued if requesting a change of Organ Donor Designation Status)

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 the fees above and included in your payment by check/money order. You must also check the block provided in Section F to ensure proper handling of your contribution.

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).

NOTE: For Photo Exemption, you must be out of state for the entire next 60 days.

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.

CLASS INFORMATION

CLASS C (Minimum age 16) Required to operate a single non-commercial* vehicle not over 26,001 pounds gross vehicle weight rating (such as passenger car, station wagon, or small truck) or any such vehicle, except those requiring a motorcycle classiication, that does not meet the deinition of

Class A or Class B. (Class C permit does not include any other class.)

CLASS B (Minimum Age 18) Required to operate a non-commercial* single vehicle of 26,001 pounds or more gross vehicle weight rating or any such vehicle towing a trailer not over 10,000 pounds gross weight. (Class B permit includes Class C).

CLASS A (Minimum Age 18) Required to operate a combination non-commercial* vehicle with a gross vehicle weight rating of 26,001 pounds or more, provided the gross vehicle rating of the vehicle being towed is in excess of 10,000 pounds. (Class A permit includes Classes B and C.)

CLASS M If adding, extending, changing, or correcting a Class M, you MUST complete a Motorcycle Learner's Permit Application (DL-5).

NOTE: The holder of a Non-Commercial Class A, B, or C driver's license will also be authorized to drive a moped.

*The term includes an implement of husbandry, certain motorized construction equipment not intended for on-road use, or any motor home or recreational trailer operated solely for personal use.

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.