Form Dl-80cd - Commercial Driver'S License Application To Duplicate/correct
ADVERTISEMENT
1
2DL-80CD (2-16)
cOMMerciAl DriVer’S licenSe APPlicAtiOn
to duPliCate/CorreCt
Federal regulation requires cDl holders to provide proof of citizenship
or legal Presence. For more information please see back of form.
Bureau of Driver Licensing • P.O. Box 68272 • Harrisburg, PA 17109-8272
A
Please read imPortant information on the BaCK. you must ComPlete all Parts of seCtion a.
Driver's License Number
LAST NAME
JR/ETC.
FIRST NAME
MIDDLE NAME
DATE OF bIRTh
TELEphONE NuMbER (8:00 A.M.-4:30 p.M.)
E-MAIL ADDRESS
Month
Day
Year
B
aPPliCation for duPliCate (Check one)
duPliCate reQuired due to:
orGan donor desiGnation
CDL Learner’s Permit and/or Knowledge Test Authorization
Lost
Stolen
Pennsylvania strongly supports organ and
Mutilated
Change of Address
CDL Camera Card (If checked, form MUST BE NOTARIZED)
tissue donation because of its life-saving
Correction
and life-enhancing opportunities.
CDL Photo License
Other _______________________________
remove
add
School Bus Driver Endorsement Card
Never Received
(MUST BE NOTARIZED - No Fee Required)
C
ChanGe or CorreCtion only (important information on reverse side)
address ChanGe -
Proof of Address must be provided, see 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.
street address
City
state
ZiP Code
PA
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
o
o
o
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
droP PrivileGe:
Month
Day
Year
FEET
INChES
class M
hazmat endorsement
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
D
to a Driver License Examination Center to surrender your out-of-state license and make application for a replacement PA license.
1.
YES
NO - Is your driver's license or driving privilege suspended or revoked in this state or any other state?
o
o
2.
YES
NO - Do you have any pending criminal charges or driving violations in this state or any other state which may carry a
o
o
possible penalty of suspension or revocation of your driver’s license or driving privilege?
If yes, give state_____________ Date ______________ and Reason ______________________________________________
E
authoriZation and CertifiCation
this seCtion must Be notariZed
AFFADAVIT: This section must be notarized when applying for replacement
Veterans Designation: I certify under penalty of law that I am a qualified applicant and hereby request it be
(duplicate) Commercial License or Camera Card. You are entitled to a free
added to my product. I understand that misrepresentation will result in the cancellation of my driver’s license.
replacement ONLY if this application is completed within 90 days of the original
I certify under penalty of law that all information given on this application is true and correct. I hereby authorize the
date of issuance and the original was never received due of loss in the mail.
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
SubSCRIbED AND SwORN
to furnish them with my driving record for the purpose of processing this form. I hereby acknowledge this day that I
MO
DAY
YEAR
TO bEFORE ME:
have received notice of the provisions of Section 3709 of the Vehicle Code.
(See reverse for provisions.)
Signature of person Administering Oath
I wish to contribute $1.00 to the Organ Donation Awareness Trust Fund. (see reverse)
I wish to contribute $3.00 to the Veterans’ Trust Fund. (see reverse)
fee
s
e
SEE REVERSE FOR FEES
siGn in PresenCe of notary
a
WARNING: Misstatement of fact
X
siGn
is a misdemeanor of the third
l
degree punishable of up to $2,500
here
and/or imprisonment up to 1 year
(18 Pa C.S. Section 4904(b)).
APPlicAnt’S SignAture in ink
(DAte)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal