Form 4424 - Request For National Driver Register File Check On Current Or Prospective Employee

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MISSOURI DEPARTMENT OF REVENUE

MOTOR VEHICLE AND DRIVER LICENSING DIVISION

P.O. BOX 2167

FORM

JEFFERSON CITY, MO 65105-2167

4424

REQUEST FOR NATIONAL DRIVER REGISTER FILE CHECK

(REV. 07-2009)

ON CURRENT OR PROSPECTIVE EMPLOYEE

EMPLOYER INFORMATION

EMPLOYER OR AGENCY NAME

PLEASE CHECK IF RAILROAD COMPANY

MAILING ADDRESS

TELEPHONE NUMBER

(

)

CITY

STATE

ZIP CODE

FAX NUMBER

(

)

I certify the individual named below is an employee, or has applied to become an employee, of the company in a position which involves the

operation of a motor vehicle, locomotive or aircraft. (Signature required if submitted by employer)

EMPLOYER’S SIGNATURE

DATE

EMPLOYEE INFORMATION

FULL LEGAL NAME (LAST, FIRST, MIDDLE)

OTHER NAMES USED (MAIDEN, PRIOR NAME, NICKNAME, PROFESSIONAL NAME, OTHER)

HOME TELEPHONE NUMBER (OPTIONAL)

(

)

RESIDENCE ADDRESS

WORK TELEPHONE NUMBER (OPTIONAL)

(

)

CITY

STATE

ZIP CODE

DRIVER’S LICENSE NUMBER

ISSUING STATE

SOCIAL SECURITY NUMBER (OPTIONAL - SEE REVERSE SIDE)

BIRTHDATE (MONTH, DAY, YEAR)

SEX

HEIGHT

WEIGHT

EYE COLOR

MALE

FEMALE

I am an employee, or have applied to become an employee, of the above named company in a position which involves the operation of a motor vehicle,

locomotive or aircraft. I authorize the Department of Revenue and the National Driver Register to furnish, for this one time only, information pertaining to my

driving record to the company identified above. Note: See the back side of this form for information on NDR.

EMPLOYEE’S SIGNATURE

DATE

NOTARY INFORMATION

(Required only if request form is not delivered in person by the current/prospective employee)

NOTARY PUBLIC EMBOSSER OR

STATE

COUNTY (OR CITY OF ST. LOUIS)

BLACK RUBBER STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF

YEAR

USE RUBBER STAMP IN CLEAR AREA BELOW.

NOTARY PUBLIC SIGNATURE

MY COMMISSION

EXPIRES

NOTARY PUBLIC NAME (TYPED OR PRINTED)

DEPARTMENT OF REVENUE USE ONLY

PROOF OF IDENTIFICATION (REQUIRED ONLY IF EMPLOYEE DELIVERS REQUEST FORM)

REMARKS/TELLER STAMP

FEE CHARGED

VALID-OUT-OF STATE LICENSE NUMBER ______________________________

BIRTH CERTIFICATE NUMBER ______________________________________

MILITARY DISCHARGE PAPERS ID NUMBER __________________________

PASSPORT NUMBER ______________________________________________

US IMMIGRATION RESIDENT ALIEN NUMBER __________________________

OTHER __________________________________________________________

TWO DOCUMENTS WITNESSED BY ______________________________________

Information furnished from this request is governed by Federal and State Protection Acts and the Federal Fair Credit Reporting Act. It is to be used for the sole

purpose for which it was requested. Any other use or dissemination of the information shall be unlawful. Penalties may include up to one year in jail and a

$10,000 fine, according to Section 208 of Public Law 97-364. See reverse side.

MO 860-2595 (07-2009)