Form 4684 - Notice Of Failure To Pass A Drug, Alcohol Or Chemical Test Regarding Persons Possessing School Bus Endorsements

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MISSOURI DEPARTMENT OF REVENUE
FORM
DRIVER LICENSE BUREAU
4684
NOTICE OF FAILURE TO PASS A DRUG, ALCOHOL OR CHEMICAL TEST
REGARDING PERSONS POSSESSING SCHOOL BUS ENDORSEMENTS
(REV. 11-2005)
I hereby certify that the following employee:
FIRST NAME
MIDDLE INITIAL
LAST NAME
DRIVER LICENSE NUMBER
DATE OF BIRTH
ADDRESS
CITY
STATE
ZIP CODE
is employed by:
NAME OF COMPANY/CORPORATION
CONTACT PERSON
TELEPHONE
ADDRESS
CITY
STATE
ZIP CODE
I further certify that on ________________________________________________ , the above employee
(MONTH/DAY/YEAR)
failed to pass
refused to complete a(n):
drug test (enclose copy of test results)
alcohol test (enclose copy of test results) administered by _________________________________________________
chemical test (enclose copy of test results)
that was administered pursuant to the requirements of any federal or state law, rule or regulation regarding the operation of
a school bus.
SIGNATURE OF EMPLOYER OR OFFICER OF EMPLOYER
DATE
Please send the completed document to the following address:
Driver License Bureau
P. O. Box 200
Jefferson City, MO 65105-0200
Telephone Number: (573) 751-2730
Fax Number: (573) 751-0466
MO 860-2770 (11-2005)
DOR-4684 (11-2005)

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