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 Identication 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)
X
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 Identication Number for the purpose of identication. 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 Ofce 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 )
QualiedWithoutRestrictions
QualiedWithRestrictions
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/
20/
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 qualied applicant and hereby request it be added to my product. I understand that misrepresentation will result
in the cancellation of my driver's license.
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