DL-176 (4-09)

MILITARY STATUS ENDORSEMENT CARD

APPLICATION FOR PENNSYLVANIA DRIVERS LICENSE Bureau of Driver Licensing
P.O. Box 68272
PLEASE TYPE OR PRINT ALL INFORMATION IN BLUE OR BLACK INK 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 Drivers 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 drivers
may seek a duplicate commercial drivers license (form DL-80CD), or renewal of a commercial drivers license (form DL-143CD, if
within six months of license expiration date); our most current forms are available online at www.dmv.state.pa.us.
PA DRIVER'S LICENSE NUMBER DATE OF BIRTH EXPIRATION DATE OF DRIVER'S LICENSE
MONTH DAY YEAR

LAST NAME JR., ETC.

FIRST NAME MIDDLE NAME

AGE HEIGHT SEX TELEPHONE NUMBER (8:00 A.M.-4:30 P.M.) 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?

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.
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
service or my return to Pennsylvania I will apply for renewal of my Pennsylvania Drivers License. If using a Messenger Service, I hereby

X
authorize the Department to furnish them with my driving record for the purpose of processing this form.

SIGN
APPLICANTS 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. S. Section 4904[b]).