Form 4423 - Individual Request For National Driver Register File Check - Missouri Department Of Revenue

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Form

Missouri Department of Revenue

4423

Individual Request For National Driver Register File Check

The National Driver Register (NDR) is a national clearing house of driver license information. NDR contains information provided by state

driver licensing officials for drivers whose licenses have been canceled, denied, revoked or suspended or who have been convicted of

certain serious traffic violations.

The following information is required by the NDR to conduct a search of the NDR file. You must submit your request by mailing it to the

address listed on the reverse side of this form. Your request, using this form, must be signed in the presence of a notary public. You

may not request information on anyone other than yourself. The fee per record is $2.82.

The response to your request will be mailed from the NDR to the address you furnish below.

Last Name

First Name

Middle

Other Names Used (Maiden, Prior Name, Nickname, Professional Name, Other)

Home Telephone Number

(

)

___ ___ ___

___ ___ ___ ___

Mailing Address

Work Telephone Number

(

)

___ ___ ___

___ ___ ___ ___

City

State

Zip Code

Driver License Number

Issuing State Social Security Number (Optional - See Reverse Side) Sex

Male

Female

Birthdate (MM/DD/YYYY)

Height

Weight

Eye Color

Fax Number

(

)

___ ___ ___

___ ___ ___ ___

____ ____ / ____ ____ / ____ ____ ____ ____

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Driver’s Signature

Date (MM/DD/YYYY)

___ ___ /___ ___ /___ ___ ___ ___

Subscribed and sworn before me, this

Embosser or black ink rubber stamp seal

day of

year

State

County (or City of St. Louis)

My Commission Expires (MM/DD/YYYY)

___ ___ /___ ___ /___ ___ ___ ___

Notary Public Signature

Notary Public Name (Typed or Printed)

Proof of Identification (Required Only If Driver Delivers Request Form)

Remarks and Teller Stamp

Valid-Out-Of State License Number ________________________________

Birth Certificate Number _________________________________________

Military Discharge Papers Identification Number ______________________

Passport Number ______________________________________________

US Immigration Resident Alien Number ____________________________

Other ________________________________________________________

Two Documents Witnessed By ______________________________________

The National Register’s files contain information furnished by the states. Any specific information about the driver history, or a request for the entire

driver history, may be obtained only from the state(s) where the detailed information is recorded. The state(s) maintaining records are the only

contacts able to correct records in error, and the NDR will correct its records when so advised by the state that reported the incorrect information.

See reverse side.

Form 4423 (Revised 06-2016)