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PennDOT - Application for Initial Identification

SIGNATURE OF EXAMINER DATEBADGE CENTER LAST NAME FIRST NAME MIDDLE NAMEDATE OF BIRTHSEX SOCIAL SECURITY NUMBER OR DRIVER'S LICENSE NUMBERMONTH I HAVE NEVER HELD A PA DRIVER'S LICENSE/PERMIT OR Identification CARD AND I AM APPLYING FOR AN Initial Identification CARD. (You must apply in person at any Driver License Center.) CURRENTLY HOLD A PA DRIVER'S LICENSE/PERMIT AND AM APPLYING FOR A NON-DRIVER Identification CARD FOR THE FOLLOWING REASON:I am surrendering my driving privilege for health reasons that may affect my ability to safely operate a motor vehicle.

CERTIFICATION (SIGN AND ENTER DATE OF APPLICATION) DEPARTMENTAL USE ONLY ID NUMBER _____ I am under the age of 18 years and I hereby request Organ Donor . designation on my Pennsylvania I.D. Card. Applicants 18 years of age

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