APPLICATION FOR REVISION/RETURN OF CDL …

1 A APPLICANT INFORMATIONDRIVER'S license NUMBER LAST NAME JR/ETCMIDDLE NAMEFIRST NAMEDATE OF BIRTH (must be listed)TELEPHONE NUMBER (8:00 TO 4:30 )E-MAIL ADDRESS Month DayYear DL-100CD (7-19) APPLICATION FOR REVISION/RETURNOF CDL CLASSIFICATIONCOMPLETE ALL SECTIONSSOCIAL SECURITY NUMBERB APPLICANT CERTIFICATION OPTIONS - Check One Option ONLY and Appropriate Box(s) (see reverse for fee information)C AUTHORIZATION, CERTIFICATION AND AFFIDAVIT - Always complete and FEE and SIGN BELOWI acknowledge that receiving a Pennsylvania Permit, license or ID card will cancel or invalidate any Permit, license or ID card from another state. I certify under penalty of law that all information given on this APPLICATION is true and correct.

2 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. I hereby apply for replacement (duplicate) due to a change or return of CDL classification. I hereby acknowledge this day that I have received notice of the provisions of Section 3709 of the Vehicle Code. (See reverse for provisions.) If using a Messenger Service, I hereby authorize the Department to furnish them with my driving record for the purpose of processing this form (See the reverse side for instructions on how to calculate the fee for Option 3.)

3 XSIGNHEREWARNING: Misstatement of fact is a misdemeanor of the third degree punishable by a Fine of up to $2,500 and/or imprisonment of up to 1 year [18 PA 4904 (6)].SUBSCRIBED AND SWORNTO BEFORE ME: MO. DAY YEARS ignature of Person Administering Oath SIGN IN PRESENCE OF NOTARYNOTARIZATIONS E A LBureau of Driver Licensing Box 68272 Harrisburg, PA 17109-8272 Option 1. o I am requesting that my CDL classification be dropped in accordance with Section 1504 of the PA Vehicle Code. I further understand that obtaining CDL qualifications in the future will require completion of all knowledge and skills testing. I hereby request my classification to be non-commercial class:m A or m B or m C and/or m MOption 2.

4 O I am requesting a change to my CDL classification to a lower CDL classification, CDL restriction and/or endorsement. I hereby request my CDL classification to be a commercial class:m A or m B or m C and/or m MCDL Restriction: m CWith endorsement:m H m X (Hazardous Materials and Tanker) m N m P m T m S Option 3. o As a result of the disqualification of my commercial driving privilege, (in accordance with Section 1617 of the PA Vehicle Code) I am applying for a non-commercial class:m C and/or m M licenseOption 4. o My disqualification period has been served and I am applying for the return of my previous CDL $Signature in InkPAID BY: Debit/Credit CardCheck Money Order Payable to PennDOT (PennDOT Driver license Centers do not accept cash.)

5 The most current version of this form can be found at: your completed and signed APPLICATION with your check or money order made payable to PennDOT ,to: Bureau of Driver Licensing, Box 68272, Harrisburg, PA 1 If your license will expire within six months, you must attach form DL-143 (Non-Commercial Driver's license / APPLICATION for Renewal). This form can be found on our website listed Class A, B, or C ..$ with Class M or Class M Only ..$ If your license will expire in more than six months, the replacement fee is:Non-Commercial Class A, B, or C ..$ Non-Commercial with Class M or Class M Only ..$ 2 (fee depends on your license expiration date) Attach form DL-143CD ( APPLICATION for renewal of CDL).

6 This form can be found on our website listed above. OPTION 3 If your license will expire within two months, you must attach form DL-143 (Non-Commercial Driver's license / APPLICATION for Renewal). This form can be found on our website listed Class C ..$ with Class M or Class M only ..$ If your license will expire in more than two months, the replacement fee is:Non-Commercial Class C ..$ Class C with Class M ..$ 4 (fee depends on your license expiration date) Attach form DL-143CD ( APPLICATION for renewal of CDL). This form can be found on our website listed above. If your license will expire in more than six months, determine if your license was renewed while you wereunder disqualification: n If your license WAS NOT renewed, the fee for a replacement CDL is:Class A, B, or C.

7 $ A, B, or C with Class M.. $ n If your license WAS renewed, include the balance of your commercial renewal fee in addition to your duplicate fee based on the number of months left until your license expires. You must also attach form DL-6 (Ten Year HistoryInformation). This form can be found on our website listed you have questions regarding completion of this APPLICATION , please contact us Monday thru Friday between 8:00 and 5:00 us at: (717) 412-5300. TTY callers - please dial 711 to reach usPROVISIONS OF SECTION 3709 OF THE VEHICLE CODES ection 3709 provides for a fine of up to $300 for dropping, throwing or depositing, upon any highway, or upon any other public or private property without the consent of the owner thereof or into or on the waters of this Commonwealth, from a vehicle, any waste paper, sweepings, ashes, household waste, glass, metal, refuse or rubbish or any dangerous or detrimental substance, or permitting any of the preceding without immediately removing such items or causing their any violation of Section 3709, I may be subject to a fine of up to $300 upon conviction.

8 Including any violation resulting from the conduct of any other persons present within any vehicle of which I am the Class A, B, C ..$ Class A, B, C w/Hazmat ..$ Class A, B, C w/Class M ..$ Class A, B, C w/Hazmat & Class M ..$ of Months CDL Fee:6 - 12 Months ..$ - 24 Months ..$ - 36 Months ..$ 37 - 48 Months ..$ (7-19)Commerical Class A, B, C ..$ Class A, B, C w/Hazmat ..$ Class A, B, C w/Class M ..$ Class A, B, C w/Hazmat & Class M ..$