Fillable Printable Non-Commercial Learner's Permit Application - Pennsylvania

Non-Commercial Learner's Permit Application - Pennsylvania

LICENSE REQUIRED FEE

  4-Year Photo $29.50

  2-Year Photo (Age 65 & Over) $19.00

DRIVER'S LICENSE

NUMBER/I.D. NUMBER:

ALL QUESTIONS MUST BE ANSWERED (Check [4] Applicable Block) YES NO

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

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

AUTHORIZATION AND CERTIFICATION

1. Have you ever held or possessed a PA Driver's License/Learner's Permit/Photo Identication Card?..........................................................

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? .......................................................................................................... 

(APPLICANT'S SIGNATURE IN INK) (DATE)

SIGN

HERE

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 Identication Number for the purpose of identication. 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 ne of up to $2,500 and/or imprisonment up to 1 year (18 Pa. C.S. Section 4904[b]).

 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 hereby certify that I am a resident of the Commonwealth of Pennsylvania.

YOU MUST APPLY IN PERSON

DL-180 (1-15)

PERMIT(S) DESIRED FEE

CLASS A (Combination Vehicle over 26,000),  CLASS B (Truck or Bus over 26,000) OR  CLASS C (Automobile) $5.00

 CLASS M (Motorcycle) MSEA Fee is included $15.00

enter fee

for each

item

checked

TOTAL $

CHECK

DESIRED

PERMIT(S)

MUST

CHECK

ONE

STREET ADDRESS - A Post Ofce Box number may be used in addition to the actual residence

address, but cannot be used as the only address.

CITY

ZIP CODE

STATE

YES NO

VISION SCREENING

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

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

CHECK (3 )

 QualiedWithoutRestrictions

 QualiedWithRestrictions

Corrective Lenses Other: ______________________________________________

DATE OF ISSUE:

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.

_____________________________________ ___________

(SIGNATURE OF EXAMINER) (DLE NO.)

EXAM CENTER:

MONTH DAY YEAR

FOR OFFICIAL USE ONLY

enter fee for

license checked

EYE COLOR (Please check one): BLUE BROWN GREEN HAZEL PINK BLACK GRAY DICHROMATIC OTHER ________________

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

MONTH

DAY YEAR

LAST NAME (S)

DATE OF BIRTH

JR./ETC

FIRST NAME MIDDLE NAME

SEX

FEET

INCHES

HEIGHT

COMPLETE ALL ITEMS

Uncorrected

Corrected

20/ Right Eye

20/ Left Eye

20/ Both Eyes

R L Fields R L

20/

SOCIAL SECURITY NUMBER

________________________________________________________________

(PROVIDER SIGNATURE - must match reverse)

NON-COMMERCIAL LEARNER'S PERMIT APPLICATION

COMPLETED BY DRIVER LICENSE EXAMINER OR A PROVIDER

COMPLETED BY DRIVER LICENSE EXAMINER ONLY

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

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

ENTER FEE FOR

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 CANNOT be accepted)

Veterans Designation: I certify under penalty of law that I am a qualied applicant and hereby request it be added to my product. I understand that misrepresentation will result

in the cancellation of my driver's license.

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 ofcial 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

ofcial 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.

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

 Neurological disorders Neuropsychiatric disorders Circulatory disorder Cardiac disorder Hypertension

 Uncontrolled Epilepsy Uncontrolled Diabetes Cognitive ImpairmentAlcohol abuseDrug abuse

 Conditions causing repeated lapses of consciousness (e.g. epilepsy, narcolepsy, hysteria, etc.)

all information in this section MUST be completed in full by a health care provider

to meet identification requirements you must present the following:

u.s. Citizens -

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.) No