DL 55 (1010/2013)
NATIONAL DRIVER REGISTER FILE CHECK
EMPLOYER REQUEST
Purpose: Employers use this form to request a National Driver Register (NDR) file check on a current or prospective employee.
Instructions: Complete this form and give to the current or prospective employee undergoing the check. Employee submits the completed form to any DMV customer service center or mails it to DMV at the above address.
Note: If employee submits the form to DMV in person, two proofs of identification are required. If employee does not submit the form to DMV in person, it must be notarized prior to submission.
EMPLOYER INFORMATION
EMPLOYER OR AGENCY NAME |
CHECK ONE (if applicable) |
|
|
|
|
|
|
|
|
AIR CARRIER |
|
|
RAILROAD COMPANY |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AUTHORIZED REPRESENTATIVE NAME |
TELEPHONE NUMBER |
|
EMAIL ADDRESS |
|
|
( |
) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
STREET ADDRESS |
CITY |
|
|
|
STATE |
ZIP CODE |
|
|
|
|
|
|
|
|
|
|
I certify the individual named below is an employee or has applied to become an employee of this company in a position which involves the operation of a motor vehicle, locomotive or airplane. (Signature required if form submitted by employer)
AUTHORIZED REPRESENTATIVE SIGNATURE |
DATE (mm/dd/yyyy) |
|
|
EMPLOYEE INFORMATION/CERTIFICATION
FULL LEGAL NAME (last) |
|
|
|
|
|
(first) |
|
|
(middle) |
|
(suffix) |
|
|
|
|
|
|
|
|
|
OTHER NAMES USED (maiden, prior name, nickname, professional name, other) |
|
DAYTIME TELEPHONE NUMBER |
|
|
|
|
|
|
|
|
( |
) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
STREET ADDRESS |
|
|
|
|
|
CITY |
|
|
|
STATE |
|
ZIP CODE |
|
|
|
|
|
|
|
|
|
|
|
|
DRIVER LICENSE NUMBER |
|
|
|
|
|
ISSUING STATE |
|
SOCIAL SECURITY NUMBER (see reverse side) |
|
|
|
|
|
|
|
|
|
|
BIRTHDATE (mm/dd/yyyy) |
GENDER |
|
|
HEIGHT |
|
WEIGHT (lbs) |
EYE COLOR |
|
|
|
M |
|
F |
ft. |
in. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
I certify that 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 airplane and I authorize the Department of Motor Vehicles and the National Driver Register to furnish, for this one time only, information pertaining to my driving record to the company identified above.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation
EMPLOYEE SIGNATURE |
DATE (mm/dd/yyyy) |
|
|
NOTARIZATION (must be completed by notary public)
REQUIRED ONLY IF EMPLOYEE DOES NOT SUBMIT THIS FORM TO DMV IN PERSON
Commonwealth of Virginia, city or county of _____________________________________ subscribed and
sworn before me on this _________________ day of __________________________________________
(MONTH)(YEAR)
by___________________________________________________ in the city or county and state aforesaid.
REGISTRATION NUMBER (6 digits)
MY COMMISSION EXPIRES (mm/dd/yyyy)
Proof of Identification - Two (2) proofs of identification required if employee submits this form in person to CSC.
□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 privacy 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 Public Law 97-364 Section 208 and 104-264.
DL 55 (1010/2013)
Page 2
NDR INFORMATION FOR THE EMPLOYER/EMPLOYEE
WHAT IS NDR?
The National Driver Register (NDR) is a computerized database of information about drivers who have had their licenses canceled, denied, revoked or suspended, or who have been convicted of serious traffic violations such as driving while impaired by alcohol or drugs.
State motor vehicle agencies provide NDR with the names of persons who have lost their driving privilege or who have been convicted of a serious traffic violation. When a person applies for a driver's license the state checks to see if the name is on the NDR file. If a person is recorded by the NDR as a problem driver, the license may be denied.
RECORD REQUESTS
Any person may request and obtain a copy of their NDR record if one exists.
EMPLOYER REQUESTS FOR NDR FILE CHECKS
Your employer or potential employer must obtain your authorization when requesting 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) and Public Law 104-264, as amended (49 U.S.C. 30305, delegation of authority at 49 CFR 1.50).
SOCIAL SECURITY NUMBER
You do not have to disclose your social security number. However, providing the number will help to identify your record. This information is collected to assist in obtaining the document(s) requested and for DMV's record keeping.
INFORMATION THAT WILL BE ON THE NDR REPORT
The NDR report indicates jurisdictions in which you may have had your license revoked or suspended, or where you may have been convicted of a serious traffic violation.
Information on your NDR report will include:
●Your name, date of birth (month, day, year), gender, description, and license number.
●All possible record matches, by state, based on your identification data.
●A statement indicating that the possible record matches may not be the same person for whom the record was requested. This statement is necessary because records may have the same or similar names, dates of birth, and other identifying information and may not pertain to you.
●The address and telephone number for each state drivers licensing agency where additional information can be secured.
●If the NDR has no record for you in their files, the report will indicate this.
INFORMATION THAT WILL NOT BE ON THE NDR REPORT
Suspension, revocation, or conviction data is not given on the NDR report. Your employer will need to contact the state in which each record originated to obtain this information and to verify each possible match. The information the state provides may affect your employment status.
YOUR RIGHT OF REVIEW
You have the right to review the record(s) that pertain to you and provided to your employer or potential employer.
