CITY STATE PA ZIP CODE

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APPLICATION FOR REPLACEMENT OF A VALID WITHOUT PHOTO LICENSE WITH A PHOTO LICENSE upon RETURN OF THE DRIVER TO PENNSYLVANIAPLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATIONDL-58EF (5-18)DRIVER INFORMATION Type or Print All InformationDRIVER S LICENSE NUMBER LAST NAME JR/ETC. FIRST NAME MIDDLE NAMEA DATE OF BIRTH HEIGHT EYE COLOR TELEPHONE NUMBER (8:00 :30 ) E-MAIL ADDRESS (if applicable) Month Day YearNEWSTREETADDRESSCITY PAZIP CODESTATEBCSIGN IN PRESENCE OF NOTARY SUBSCRIBED ANDSWORN TO BEFORE ME MO. DAY YEARSIGNATURE OF PERSON ADMINISTERING OATHSEALI acknowledge that receiving a Pennsylvania Permit, License or ID card will cancel or invalidate any Permit, License or ID card from another STATE .

application for replacement of a valid without photo license with a photo license upon return of the driver to pennsylvania please type or print in blue or black ink ...

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