Form Dl 55 - National Driver Register File Check - Employer Request

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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

(

)

STATE

STREET ADDRESS

CITY

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

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

NOTARY PUBLIC SEAL

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)

NOTARY PUBLIC NAME

NOTARY PUBLIC SIGNATURE

DMV USE ONLY

Proof of Identification -

Remarks/CSR Stamp

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.