Form 4423 - Individual Request For National Driver Register File Check
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MISSOURI DEPARTMENT OF REVENUE
FORM
MOTOR VEHICLE AND DRIVER LICENSING DIVISION
P.O. BOX 2167
4423
JEFFERSON CITY, MO 65105-2167
(REV. 07-2009)
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 $5.88.
The response to your request will be mailed from the NDR to the address you furnish below.
REQUESTOR INFORMATION (PLEASE TYPE OR PRINT CLEARLY)
FULL LEGAL NAME (LAST, FIRST, MIDDLE)
HOME TELEPHONE NUMBER (OPTIONAL)
(
)
OTHER NAMES USED (MAIDEN, PRIOR NAME, NICKNAME, PROFESSIONAL NAME, OTHER)
WORK TELEPNONE NUMBER (OPTIONAL)
(
)
MAILING ADDRESS
FAX NUMBER
(
)
CITY
STATE
ZIP CODE
DRIVERS LICENSE NUMBER
ISSUING STATE
SOCIAL SECURITY NUMBER (OPTIONAL-SEE REVERSE SIDE)
BIRTH DATE (MONTH, DAY, YEAR)
SEX
HEIGHT
WEIGHT
EYE COLOR
MALE
FEMALE
DRIVER’S SIGNATURE
DATE
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK 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 DRIVER DELIVERS REQUEST FORM)
REMARKS / TELLER STAMP
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 ______________________________________________
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 report-
ed the incorrect information.
See reverse side.
MO 860-2594 (07-2009)
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