Form 4685 - Driving Skills Examination Report
ADVERTISEMENT
1MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU
FORM
PO BOX 200
TELEPHONE: (573) 751-1887
4685
JEFFERSON CITY, MO 65105-0200
FAX: (573) 522-8174
DRIVING SKILLS EXAMINATION REPORT
(REV. 01-2012)
NAME
LAST
FIRST
MIDDLE INITIAL
LICENSE/PERMIT NUMBER OR SOCIAL SECURITY NUMBER (if known)
STREET ADDRESS
DATE OF BIRTH
SEX (M/F)
__ __ / __ __ / __ __ __ __
CITY
STATE
ZIP CODE
RECORD OF EXAMINATIONS
You have failed to pass a driving skills examination on three occasions as listed below.
You have failed to pass your
4th
5th
6th driving skills examination as listed below.
You may not take another driving skills examination until you receive written authorization from the Director of Revenue.
EXAMINATION
ROAD RESULTS
EXAMINER NUMBER
DATE
SITE
(IF KNOWN)
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
q
q
q
q
q
q
Type of license applicant is testing for:
Class A
Class B
Class C
Class E
Class F
Class M
q
q
q
q
School Bus
Airbrake
Passenger
Endorsement/Qualification
q
q
Was this test court ordered?
No
Yes
If yes, attach a copy of the court order
q
q
Was this test required based on vision?
No
Yes If yes, attach a copy of form DOR-999
Check the applicable skills test box on the back of the permit with a permanent marker.
Driver Examiner Comments:
INSTRUCTIONS
You must mail this notice to the Driver License Bureau, 301 West High Street, Room 470, P.O. Box 200, Jefferson City, Missouri
65105-0200 or fax it to (573) 522-8174. The Driver License Bureau will advise you in writing of your requirements. Another driving
skills examination will not be administered until you complete each of those requirements. Any driver training completed prior to our
notification will not be accepted.
EXAMINER
EXAMINER NO.
DATE
__ __ / __ __ / __ __ __ __
VISIT OUR WEB SITE AT
DISTRIBUTION: WHITE — EXAMINEE
CANARY — EXAMINER
DOR-4685 (01-2012)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial