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Iver s License. Form must be notarized option 2: Replacement License. Form must be notarized (See reverse for fees) DRIVER INFORMATION Type or Print All Information Driver s License Number JR/ETC. LAST NAME FIRST NAME MIDDLE NAME Month B D E PA R T M E N T O F T R A N S P O R TAT I O N Bureau of Driver Licensing P.O. Box 68272 Harrisburg, PA 17106-8272 DATE OF BIRTH Day Year Telephone Number (8:00 a.m.-4:30 p.m.) E-mail address (if applicable) ( ) ADDRESS CHANGE.

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