military status endorsement card - dot.state.pa.us

1 DL-176 (6-17). military status endorsement card application for pennsylvania driver's license please type or print all information in blue or black ink Bureau of Driver Licensing Box 68272 Harrisburg, PA 17106-8272. no fee reQuired - This form is for use by military personnel and dependents who are in active service in the Armed Forces of the United states outside the Commonwealth of Pennsylvania. Issuance of a PA military status endorsement Card will assure that the PA Driver's record remains valid during extended military absences from the Commonwealth. For Commercial Driver License holders, only the record will show this status , as a PA military status endorsement Card is not applicable, though driver's may seek a duplicate commercial driver's license (form DL-80CD), or renewal of a commercial driver's license (form DL-143CD, if within six months of license expiration date); our most current forms are available online at PA DRIVER'S LICENSE NUMBER DATE OF BIRTH EXPIRATION DATE OF DRIVER'S LICENSE.

2 MONTH DAY YEAR. LAST NAME JR., ETC. FIRST NAME MIDDLE NAME. AGE HEIGHT SEX TELEPHONE NUMBER (8:00 :30 ) E-MAIL ADDRESS (If applicable). FEET INCHES. EYE COLOR (please check one): BLUE BROWN GREEN HAZEL PINK BLACK GRAY DICHROMATIC OTHER:_____. address This address will be represented on your PA Driver License record until your discharge from the military service, and/or you notify the Bureau of a new address change. An endorsement card will be mailed to this address. STREET ADDRESS. CITY STATE ZIP CODE. if you are a registered voter in pa, would you like us to notify your county voter registration office of this change?

3 Q yes q no if you are not a registered voter, you may contact your county voter registration office. status - check (4) appropriate block and attach a copy of military photo id card, or provide a letter from the employer to document your status , on their letterhead. if you are the immediate family of a person meeting one of the allowable exceptions, the documentation should be of the person employed. additionally, you must indicate your relationship to that person. q I am on active service in the Armed Forces of the United states outside the Commonwealth of Pennsylvania. q I am the spouse of a person on Active Service with whom I reside outside the Commonwealth of Pennsylvania.

4 Q I am the dependent child of a person on Active Service with whom I reside outside the Commonwealth of Pennsylvania. I certify under penalty of law that all information on this document is true and correct. Within 45 days of discharge, separation from active X. service or my return to Pennsylvania I will apply for renewal of my Pennsylvania Driver's License. If using a Messenger Service, I hereby authorize the Department to furnish them with my driving record for the purpose of processing this form. sign applicant's signature here WARNING: Misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 Pa C.)

5 S. Section 4904[b]).