Form Dl-143 - Non-Commercial Driver'S License Application For Renewal

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DL-143 (12-16)

NON-COMMERCiAL DRivER'S LiCENSE

AppLiCATiON fOR RENEWAL

DO NOT Renew if license is under suspension and you have recently surrendered it.

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

LAST NAME

JR./ETC

DRIVER'S LICENSE NUMBER

FIRST NAME

MIDDLE NAME

DATE OF BIRTH

TElEPHOnE nuMBER (8:00 A.M.-4:30 P.M.)

E-MAIl ADDRESS (if applicable)

Month

Day

Year

cHANGe OR cORRecTION ONLY (Important information on reverse side)

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.

ADDRESS -

STREET ADDRESS

STATE

ZIP CODE

CITY

If you are a registered voter in PA, would you like us to notify your county voter registration office of this change?

YES

If you are not a registered voter, you may contact your county voter registration office.

NAMe cHANGe

(Please note all name changes must be done in person with original documents)

ReASON:

MARRIAGe

DIvORce

OTHeR (see reverse side)

JR., ETC.

LAST NAME

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:

DAY

FEET

INCHES

Drop Class M

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 center

to surrender your out-of-state license and complete an application for a PA License.

YES

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

If yes, give: State ___________ Expiration Date ________________________________

Driver's License No.________________________________________________________

YES

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

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 of suspension

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

If yes, give state_____________ Date ________________________________

and

Reason _______________________________________________________________

AUTHORIZATION AND ceRTIfIcATION (Sign and Enter Fee)

for veterans wishing to add the veterans Designation to their Driver's License or ID card: I certify under penalty of law that I am a qualified applicant and hereby request it

be added to my product. I understand that misrepresentation will result in the cancellation of my driver's license.

I certify under penalty of law that all information given on this application 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. 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 acknowledge this day that I have received notice of the provisions of Section 3709 of the

Vehicle Code. (See reverse for provisions.)

I wish to contribute $1.00 to the Organ Donation Awareness Trust Fund. If checked here, include the additional $1.00 in the amount entered in the Fee Paid block. (see reverse)

I wish to contribute $3.00 to the Veterans' Trust Fund. (see reverse)

SIGN

HeRe

DATE

APPlICAnT'S SIgnATuRE In InK

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]).

PAID BY:

Check

Money Order

Payable to PennDOT (PennDOT does not accept cash, credit or debit cards)

TOTAL $