Form 4319 - Driver Condition Report
Download a blank fillable Form 4319 - Driver Condition Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 4319 - Driver Condition Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Reset Form
Print Form
MISSOURI DEPARTMENT OF REVENUE
FORM
DRIVER LICENSE BUREAU, P.O. BOX 200
4319
301 WEST HIGH STREET, ROOM 470
TELEPHONE: (573) 751-2730
JEFFERSON CITY, MO 65105-0200
FAX: (573) 522-8174
DRIVER CONDITION REPORT
WEB SITE:
(REV 04-2010)
Please complete the Driver Condition Report if you have personal knowledge about a driver you believe is no longer
able to safely operate a motor vehicle.
You should report only your firsthand knowledge of the driver.
You should complete the entire form and sign your name on the reverse side.
After reviewing this report, the Director of Revenue may require the driver to take certain tests such as a medical, vision
or driving test.
All information contained in this report shall be kept confidential, unless released by a court order.
PERSONAL
NAME (LAST, FIRST, MIDDLE)
SOCIAL SECURITY NUMBER OR DRIVER LICENSE NUMBER
INFORMATION ON
PERSON BEING
LICENSE PLATE NUMBER
STATE OF ISSUANCE
DATE OF BIRTH
TELEPHONE NUMBER
REPORTED:
__ __ / __ __ / __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
Please complete all
ADDRESS
CITY
STATE
ZIP CODE
available information.
__ __ __ __ __
DRIVER
Describe in detail incidents or conditions about this driver. Give
specific information such as dates, places, accident reports and all
BEHAVIOR
other available information to support the need for re-examination.
Please check appropriate boxes based on
You should report only information of which you have personal
personal
knowledge
of
incident
if
knowledge or physical evidence. Do not report what you have been
applicable.
Please
give
a
detailed
told or heard.
description of incident. Age alone is not a
sufficient reason for retesting.
Traffic Violations
Lack of Attention
Dangerous Actions
Caused Traffic Accident/Incident
Poor Driving Skills
LOCATION
DATE
TIME
Lack of Knowledge of Traffic Laws
Obstructing Traffic
Other
MO 860-2507 (04-2010)
DOR-4319 (04-2010)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial