Form 4424 - Request For National Driver Register File Check On Current Or Prospective Employee Page 2

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INFORMATION FOR THE EMPLOYEE

WHAT IS NDR?

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. Any person may request an NDR file check for their driver

record and obtain a copy of the record if one exists.

EMPLOYER REQUESTS FOR NDR FILE CHECKS

Your employer is required to obtain your authorization each time the employer requests information on your record from

NDR. Data requested on this form is by the authority of Public Law 97-364.96 Stat 1740, as amended (23 U.S.C. 401 note);

delegation of authority at 49 CFR 1.50.

SOCIAL SECURITY NUMBER (Optional)

Disclosure of your social security number is not mandatory; however, providing the number will assist in obtaining the

record(s) requested.

THE FOLLOWING INFORMATION WILL BE FURNISHED ON THE NDR TRANSCRIPT:

Your name, date of birth (month, day, year), sex, height, weight and eye color (as shown on this form).

The name, date of birth, sex, height, weight, eye color and driver license number on all possible record matches

in the NDR files is based on the identification data you furnish.

A statement indicating that the possible matches furnished on the transcript may not be the same person for

whom the record has been requested. This statement is necessary because often records may have the same

name or similar name, date of birth and other identifying information and may not pertain to you.

No suspension, revocation, or conviction data will be displayed on the NDR record. Your employer will need to contact the

state where each record originated to obtain this information and verify the identity of each possible match. The state may

provide information which may affect your employment status. The address and telephone number for each state driver

licensing agency where the information can be requested will be furnished on the NDR transcript.

If the NDR has no record for you in their files, the transcript will indicate this.

As the employee, you have the right to review your record(s) from the state(s) as provided to your employer.

PLEASE SEND THE REQUESTED RECORD(S) BY

MAIL

and/or

FAX (add $0.50 per page faxed)

PAYMENT OPTIONS

CENTRAL

TOTAL RECORD FEES

CONVENIENCE FEE

PAYMENT

Records can be

FAX OR

MAIL

OFFICE

OPTIONS

obtained by walk-in,

E-MAIL

$0.00-$33.00

$1.00

VISIT

mail-in, or e-mail

$33.01-$100.00

3.00%

CASH

request,

$100.01-$250.00

2.95%

CHECK

$250.01-$500.00

2.85%

MONEY ORDER

The fee is $5.88

per record.

$500.01-$750.00

2.85%

DEBIT CARD

$750.01-$1,000.00

2.80%

DISCOVER

A convience fee will

$1,000.01-$1,500.00

2.75%

VISA

be charged for

$1,500.01-$2,000.00

2.70%

AMERICAN EXPRESS

credit/debit card

transactions.

$2,000.01 or more

2.60%

MASTERCARD

Mail to: Motor Vehicle and Driver License Bureau-Record Sales, PO Box 2167, Jefferson City, MO 65105-2167 Fax or E-Mail to: 573 526-7367 dlrecords@dor.mo.gov

Visit at: Central Office, Harry S Truman Building, Room 360, 301 West High Street, Jeffferson City, MO

If you are paying by credit/debit card you must provide the following:

NAME (AS IT APPEARS ON CARD)

CARD TYPE

CARD NUMBER

EXPIRATION DATE

__ __ / __ __

REQUESTOR’S SIGNATURE

DATE

__ __ / __ __ / __ __ __ __

THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOLLECTED FUNDS

MO 860-2595 (07-2009)