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-
DL-180 (04-03)
MIDDLE NAME
FIRST NAME
JR., ETC
.
DATE OF BIRTH
SOCIAL SECURITY NUMBER
SEX
TELEPHONE (8:00 a.m. to 4:30 p.m.)
DRIVER'S LICENSE NUMBER/I.D. NUMBER:
INCHES
HEIGHT
FEET
YEAR
DAY
MONTH
(
)
NON-COMMERCIAL
LEARNER'S PERMIT APPLICATION
PRINT ALL INFORMATION IN
BLACK OR BLUE INK
ALL QUESTIONS MUST BE ANSWERED
(Check [ ] Applicable Blocks)
YES
NO
THIS FORM IS VALID FOR 1 YEAR FROM THE DATE OF PHYSICAL EXAMINATION
The physical date may not be more than 60 days prior to your 16th birthday.
LAST NAME(S)
AUTHORIZATION AND CERTIFICATION
FOR PENNDOT USE ONLY
Exam Center: _______________________________________
Date: ________________
MEDICAL RESTRICTIONS: _____________________
Signature of Examiner: _______________________________
Badge No.: ___________
VERIFICATION OF BIRTH DATE AND IDENTITY: BIRTH CERTIFICATE OTHER ________________________________________________ QUALIFIED YES UNABLE TO DETERMINE MEDICAL QUALIFICATIONS
ENTER

FEE
FOR

EACH
ITEM

CHECKED
TOTAL
$
1. Have you ever held or possessed a PA Driver's License/Learner's Permit/Photo Identification 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 or revoked? ............................................................................................................................................................................
If yes, give state__________ date__________________, and reason ______________________________________________
3. Have you been arrested or cited in this state or any other state for any violation which carries a possible
penalty of suspension or revocation of your driver's license or driving privilege? .............................................................................
If yes, give state__________ date__________________, and reason ______________________________________________
STREET ADDRESS -
P.O. Box may be used in addition to the actual address, but cannot be used
as the only address
CITY
ZIP CODE
STATE
PERMIT(S) DESIRED
FEE CLASS A (Combination Vehicle over 26,000)
$5.00 CLASS B (Truck or Bus over 26,000)
$5.00 CLASS C (Automobile)
$5.00 CLASS M (Motorcycle) MSEA Fee is included
(see back for information)
$15.00
LICENSE REQUIRED
FEE 4-Year Photo
$26.00 2-Year Photo (Age 65 & Over)
$15.50 Organ Donation Awareness Trust Fund (I wish to contribute $1.00)
$1.00
PAID BY: Check Money Order
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]). I am under the age of 18 years and I hereby request Organ Donor designation on my PA Drivers License. Parent must check
consent block on the Parent/Guardian 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.
EYE COLOR (Please check one):
PINK
GRAY
BROWN
GREEN
HAZEL
BLACK
DICHROMATIC
BLUE
OTHER
(APPLICANT'S SIGNATURE IN INK)
(DATE)
X
SIGN
HERE 1. Neurological disorders such as to prevent reasonable control of a motor vehicle? ............................................................
2. Any Cardiac or Circulatory disorder including Hypertension such as to prevent reasonable control of a motor vehicle? ......
3. Neuropsychiatric disorders such as to prevent reasonable control of a motor vehicle? ....................................................
4. Conditions causing repeated lapses of consciousness, e.g. epilepsy, narcolepsy, hysteria, etc.? ..................................
If yes, specify: ______________________________
If seizure disorder, date of last seizure _______________
5. Alcoholism? .....................................................................................................................................................................................
6. Narcotic Addiction? ........................................................................................................................................................................
7. Uncontrolled Diabetes? .................................................................................................................................................................
8. Uncontrolled Epilepsy? ..................................................................................................................................................................
9. Immobility or Amputation of an Appendage? ..............................................................................................................................
If so, list: _____________________________________________________________________________________________
10. Does this person have any other condition that would prevent control of a motor vehicle? .................................................
If yes, list: ____________________________________________________________________________________________
NOTE: Any recommendations/additional comments must accompany this certificate on physician letterhead enclosure
PHYSICIAN INFORMATION

(Please print or type)
CHECK ONE: M.D. D.O. C.R.N.P. P.A. O.S.
NAME
STATE LICENSE NUMBER
TELEPHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
PHYSICIAN'S SIGNATURE
PHYSICAL DATE
EXAMINEE'S SIGNATURE (SIGN ONLY IN PRESENCE OF PHYSICIAN)
ALL

INFORMATION

IN

THIS

SECTION
MUST
BE

COMPLETED

IN

FULL

BY

A

MEDICAL

PROVIDER
Physician's Report of Examination
(Check [] Applicable Block)
YES
NO
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.
Non-U.S. Birth Certificates will not be accepted)
Certificate of U.S. Citizenship
(INS Form N-560)
Certificate of Naturalization

(INS Form N-550 or N-570)
PA Photo ID Card
PA Photo Driver's License
Valid U.S. Passport
U.S. Military Photo ID Card
NOTE:
Only valid Passports and original documents will be
accepted. If you have an Out-of-State Driver's License, it must be
accompanied with one of the above forms.
Non-U.S. Citizens You must bring ALL of the following:
Social Security Card (card cannot be laminated)
Valid Passport
All original INS documents
Written verification of attendance from school
(Student Status Only)
Written verification from employer (Employment Status Only)
Detailed identification information can be found on Publication 195
Documentation needed to apply for a Pennsylvania Drivers License,
Learners Permit or Identification Card. To obtain Publication 195
you can:
Visit the PA PowerPort at www.state.pa.us and type in PA
Keyword: Driver Licensing
Call us at 1-800-932-4600 or 1-800-228-0676 (TDD)
Monday through Friday from 7:00 am to 9:00 pm, or
Visit one of our Driver License Centers.
TO

MEET

RESIDENCY

REQUIREMENTS

YOU
MUST
PRESENT

TWO

OF

THE

FOLLOWING

(for customers 18 years of age or older)
:
Current utility bills
(
water, gas, electric, cable, etc.
)
Tax Records
Lease Agreements
Mortgage documents
W-2 Form
Current weapons permit
CASH

CAN
NOT
BE

ACCEPTED
TOTAL
LICENSE FEE
PERMIT FEE
MSEA FEE
PHOTO FEE
Initial Permit & 4 Year License
$31.00
$21.00
$5.00
---
$5.00
Initial Class M Permit & 4 Year License
$41.00
$21.00
$5.00
$10.00
$5.00
Initial Permit & 2 Year License (age 65+)
$20.50
$10.50
$5.00
---
$5.00
Initial Class M Permit & 2 Year License (age 65+)
$30.50
$10.50
$5.00
$10.00
$5.00
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 fee above and included in your payment by check/money order.
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. PARENT OR GUARDIAN CONSENT FORM
_____________________________________________________________________________________
(PRINT NAME OF APPLICANT)
I hereby certify that I am the minor applicant's Parent Guardian Person in Loco
Parentis or Spouse, and that I am at least 18 years of age.
I also certify that: This application is made with my full consent. I understand if I want to withdraw my consent at any time before this minor applic