APPLICATION FOR CHANGE CORRECTION/ REPLACEMENT …

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LAST NAMEJR. ETC. FIRST NAMEMIDDLE NAME DATE OF BIRTH (must be listed) LICENSE NUMBERLICENSE EXPIRATION DATE TELEPHONE NUMBER (between 8:00 - 4:30 ) DL-80OP (12-21)CHECK APPLICABLE BOXMonthDayYearACURRENT OCCUPATIONAL LIMITED LICENSE OR PROBATIONARY LICENSE (Type or print information)BAPPLICATION FOR REPLACEMENT (Check one)LOST STOLEN *NEVER RECEIVED(No Fee - Must be Notarized)THIS AREA IS FOR CHANGES OR CORRECTIONS ONLY - (Only fill in the information you want to CHANGE or correct) ADDRESS CHANGESTREET ADDRESS: A Box number may be used in addition to the actual residence address, but cannot be used as the only below if using an out-of-state address.

REPLACEMENT (DUPLICATE) Complete Sections A, B, E, (D if applicable) CHANGE OR CORRECTION=Complete Sections A, B, C, E, (D if applicable) * REGULAR CAMERA CARD PHOTO LICENSE ... Note: The Department is required to obtain the Licensee’s height and eye color under the provisions of the Pennsylvania Vehicle Code. This information will be used

  Correction, Color