U.S. Permanent Labor Certification L02773316: Aug 3, 2008

This is the html version of the file http://www.dmv.state.pa.us/pdotforms/dl_forms/dl-54b.pdf.
Google automatically generates html versions of documents as we crawl the web.
Page 1
SIGN IN PRESENCE OF NOTARY
SubSCRIbEd ANd
SwORN TO bEFORE ME
MO.
dAY
YEAR
Signature of PerSon adminiStering oath
SEE REVERSE SIdE FOR IMPORTANT INFORMATION
CheCK aPPLiCaBLe BLoCK:
1.
q
REPLACEMENT (duPLICATE) — Complete Sections a, B, C (if applicable)
and d. All requests must be notarized.
2.
q
RENEwAL, CHANGE or CORRECTION of
Pennsylvania id Card. Complete Section a, C (if
applicable) and d. Notarization is not required.
A
S
E
A
L
AuTHORIZATION ANd CERTIFICATION (SIGN ANd ENTER FEE)
d
wARNING: misstatementoffactisamisdemeanor
of the third degree punishable of up to $2,500
and/or imprisonment up to 1 year (18 Pa C.S.
Section 4904(b)).
CONSENT OF PARENT, GuARdIAN, PERSON IN LOCO PARENTIS OR SPOuSE AT LEAST 18 YEARS OF AGE. Complete if Applicant is
Less Than 18 Years of Age to give consent for Applicant's request for Organ donor designation.
Applicant's Signature in Ink
i hereby certify that i am a
o
Parent,
o
guardian,
o
Person in Loco Parentis, or
o
Spouse at least 18 years of age,
and i
o
do give consent
o
do not give consent for applicant's request for organ donor designation.
(Date)
(Signature of Parent, Guardian, Person in Loco Parentis or
Spouse at least 18 years of age-In Ink)
affidaVit:
This section must be notarized when applying for a
replacement (duplicate) Pennsylvania identification Card. You are entitled to a free
replacement onLY if this application is completed within 90 days of the original
date of issuance and the original was never received due to loss in the mail.
i certify under penalty of law that all information given on this application is true and correct. 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. if using a messenger Service, i hereby
authorize the department to furnish them with my driving record for the purpose of processing this form.
o

i am under the age of 18 years and i hereby request organ donor designation on my Pennsylvania i.d. card. Parental consent in Section e is required.
Applicants 18 years of age or older will have the opportunity to request Organ donor designation at the photo center at the time they have their
photo taken.
o

i wish to contribute $1.00 to the organ donation awareness trust fund (see reverse). if checked here, include the additional $1.00 in the amount entered in
the fee Paid block above.
b
reaSon rePLaCement required: (Check One):
YOu MuST COMPLETE ALL PARTS OF SECTION A
(Date)
o
add
(Parental consent in Section D required if under 18)
o
Add
ORGAN DONOR DESIGNATION
q
LoSt
q
StoLen
q
neVer reCeiVed
q
mutiLated
q
Change
q
CorreCtion
TELEPHONE NuMbER
8:00A.M. - 4:30P.M.
(
)
month
daY
Year
LAST NAME
PHOTO Id NuMbER
DATE OF BIRTH (must be listed)
JR./ETC
FIRST NAME
MIddLE NAME
FEE PAId
Send Check
in this amount
$
(fee information on back)
E-MAIL AddRESS (if applicable)
ZIP COdE
STATE
nAmE CHAngE
REASON:
MARRIAGE
dIVORCE
OTHER (see reverse side)
LAST
NEw
STREET
AddRESS
CITY
CHAngE OR CORRECTIOn OnLY (Important information on reverse side)
JR., ETC.
mIDDLE nAmE
FIRST NAME
SoCiaL SeCuritY numBer
-
-
month
Year
CORRECTION OF DATE OF BIRTH
mALE
FEmALE
SeX
If you are a registered voter in PA, would you like us to notify your county voter registration office of this change?
o
YES
o
nO
If you are not a registered voter, you may contact your county voter registration office.
EYE COLOR (Please check one):
bLuE
bROwN
GREEN
HAZEL
PINK
bLACK
GRAY
dICHROMATIC
OTHER __________________
_____________________________________________________________________________________________________________________________________________________________________________________
OTHER CHAngES
ADDRESS CHAngE -
A Post Office Box number may be used in addition to the actual residence address, but cannot be used as the only address. See reverse if using an out-of-state address.
PA
C
HEIGHT
feet
inCheS
X
SIGN
hERE
daY
E
Pa department of transportation • Bureau of driver Licensing
P.o. Box 68272 • harrisburg, Pa 17106-8272
PENNSYLVANIA NON-dRIVER PHOTO
IdENTIFICATION CARd
application for change
,
correction
,
replacement
,
or renewal
dL-54B (3-07)
Page 2
APPLICATION INFORMATION
• Return your completed and signed application with check or money order made payable to "PenndOT", to: bureau
of driver Licensing, P.O. box 68272, Harrisburg, PA 17106-8272.
out-of-State addreSS Change. We may not issue driver license products to an out-of-state address, except
in the case of an employee of federal or state government, armed forces personnel, or their families, whose
workplace is located outside of Pennsylvania. if this exception applies to you, please check the appropriate box
and include documentation of your status with this application.
attach a letter from your employer on their letterhead to document your status, or attach a copy of your current
Photo id issued by your employer. if you are the immediate family of a person meeting one of the allowable
exceptions, attach the documentation of the person employed. additionally, you must indicate your relationship to
that person.
i certify that my workplace is located out of state and i am employed by, or am the immediate family of a person
employed by:

o uS armed forces
o federal government
o Pennsylvania State government
relationship to person meeting exemption (check one): o Spouse o dependent Child
• the department is required to obtain the Licensee's Social Security number, height and eye color under the provisions of
Sections 1510(a) and/or 1609(a)(4) of the Pennsylvania Vehicle Code. this information will be used as identifying information
in an attempt to minimize driver license fraud. the Social Security number is not part of your public driver's record. federal
law permits the use of the Social Security Number by state licensing officials for purposes of identification.
REPLACEMENT OF
fee: $5.00 if photo was not taken with the original Camera Card.
PHOTO Id OR
fee: $10.00 if photo was taken with the original Camera Card. if photo
PHOTO Id CAMERA
image is on file, the Bureau will issue a Photo identification Card.
CARd
(Application for replacement must be notarized)
RENEwAL OF
fee: $10.00 for 4 years, if contributing to the organ donation awareness trust
PHOTO Id
fund, see information below.
CHANGE/CORRECTION
no fee required – The Bureau will issue an update card reflecting the change/correction
which must be carried with the Pennsylvania Identification Card. Notarization is not required.
IF NAME IS CHANGED by permission of court, attach a Certified Copy of The Court Order. If you desire to use a name other
than your (1) birth name, (2) spouse's surname, or (3) a name given through a Court order, you must provide documentation
that connects the names, such as original Marriage Certificate, Divorce Decree, or Court Order document along with a copy of
a Social Security Card (or records), together with copies of documents from two other sources issued in the desired name such
as: tax records, Selective Service Card, Passport, or any form of Photo i.d. issued by a governmental agency.
if Year of Birth on photo identification is incorrect, attach official birth certificate.
if Social Security number is incorrect, attach copy of Social Security Card.
ORGAN dONOR
When you are requesting or deleting the organ donor designation when replacing
dESIGNATION
your id or Photo id Camera Card, the form must be notarized and a replacement
(duplicate) fee is required.
ORGAN dONATION
You have the opportunity to make a $1.00 contribution to the fund. the additional
AwARENESS
$1.00 contribution must be added to the required id fee and included in your payment
TRuST FuNd (OdTF)
by check/money order. You must also check the block provided Section d to ensure
proper handling of your contribution.
Change your address or renew your driver's license online at www.dmv.state.pa.us
Section 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 removal.
For any violation of Section 3709, I may be subject to a fine of up to $300 upon conviction, including any violation resulting
from the conduct of any other persons present within any vehicle of which i am the driver.
dL-54B (3-07)

U.S. Permanent Labor Certification L02773316

Sunday, August 3, 2008

Pennsylvania Photo Identification Card L02773316 L24033516 L01432062 A098927620 N0000425665 jurisdoctorstud Christan Milan INS#75905662303

Massachusetts Photo Identification Card L02773316 L01432062 L24033516 jurisdoctorstud Christian Milan N0000425665 A098927620 INS#75905662303

Blog Archive

About Me