Form TA-VN-191 "Request for National Driver Register File Check on Current or Prospective Employee" - Vermont

What Is Form TA-VN-191?

This is a legal form that was released by the Vermont Department of Motor Vehicles - a government authority operating within Vermont. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 1995;
  • The latest edition provided by the Vermont Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form TA-VN-191 by clicking the link below or browse more documents and templates provided by the Vermont Department of Motor Vehicles.

ADVERTISEMENT
ADVERTISEMENT

Download Form TA-VN-191 "Request for National Driver Register File Check on Current or Prospective Employee" - Vermont

Download PDF

Fill PDF online

Rate (4.5 / 5) 34 votes
Page background image
STATE OF VERMONT
AGENCY OF TRANSPORTATION
DEPARTMENT OF MOTOR VEHICLES
120 State Street, Montpelier, VT 05603-0001
Request for National Driver Register File Check on Current or Prospective Employee
Current or Prospective Employer to Receive the NDR Search Results:
z Driver Employer z Railroad Company
Employer or Agency Name
To the specific attention of:
Business Telephone Number
Area Code
(
)
Mailing Address (Number and Street)
City, State and Zip Code
Type or Print Plainly (Avoid delays. Inquiries that cannot be read will not be processed.)
Driver's Full Legal Name (First, Middle, and Last)
Other Names Used (Maiden, Prior Name, Nickname, Professional Name, Other)
Mailing Address (Number and Street with Apartment Number if any or Rural Route/Carrier and Box Number)
Home Telephone Number
(Optional)
Area Code
(
)
City, State and Zip Code
Work Telephone Number
(Optional)
Area Code
(
)
Driver License Number and State
Social Security Number
Month, Day, and Year of Birth
Sex
Color of Eyes
Height
Weight
EMPLOYEE UNDERSTANDING: I understand that the National Driver Register (NDR) search will result in a printed report which will be
sent only to the employer or regulatory agency listed above on this form. The report will indicate either (1) that the NDR does not contain a
record matching my identification or (2) that the NDR has a probable identification (match) from one state (or more) which will be named on
the report. A separate check of state files would be required (1) to verify the identification or (2) to obtain the driving record. It is the
responsibility of the listed employer to obtain the state driver records and to determine or verify records which apply to me. Under the
Privacy Act, I have the right to request record(s) pertaining to me from the NDR. I also understand that if convictions, suspension or
revocations of mine are found which I have not shown on my applications or interviews, I might not be hired as a driver or could lose my job
as a driver, and the State where I am licensed may also take action on my driver license including suspension, cancellation, or revocation. I
hereby, with my signature, authorize a one-time file search of the NDR and any resulting reports to be sent to the employer or agency named
on this form.
Driver's Signature (Please read information on back before signing.)
Date
NOTARIZATION
Official Use Only
Required only if the NDR File Check is not made in person by the
current or prospective operator.
Date Received
Date Sent
Internal Control
Sworn to and ascribed before me
Notary Public
Seal or Stamp
this __________ day of ___________________
19__________ in the city/county of
______________________________________
State of _______________________________
TYPE OF IDENTIFICATION: z Valid Photo Driver License z State-issued Photo ID
DO NOT WRITE IN THIS SPACE - DEPT. USE ONLY!
zBirth Certificate z Valid Passport z Valid Military ID z Military Discharge Papers
z Other (specify) ______________________________________________________
Employee Verifying Applicant Identification (Print Name)
Signature
TA-VN-191 .5M 11/95 JTB
Comment = "PDPS INQUIRY SENT _________________"
(MM/DD/YY)
See Reverse Side for Additional Explanations
STATE OF VERMONT
AGENCY OF TRANSPORTATION
DEPARTMENT OF MOTOR VEHICLES
120 State Street, Montpelier, VT 05603-0001
Request for National Driver Register File Check on Current or Prospective Employee
Current or Prospective Employer to Receive the NDR Search Results:
z Driver Employer z Railroad Company
Employer or Agency Name
To the specific attention of:
Business Telephone Number
Area Code
(
)
Mailing Address (Number and Street)
City, State and Zip Code
Type or Print Plainly (Avoid delays. Inquiries that cannot be read will not be processed.)
Driver's Full Legal Name (First, Middle, and Last)
Other Names Used (Maiden, Prior Name, Nickname, Professional Name, Other)
Mailing Address (Number and Street with Apartment Number if any or Rural Route/Carrier and Box Number)
Home Telephone Number
(Optional)
Area Code
(
)
City, State and Zip Code
Work Telephone Number
(Optional)
Area Code
(
)
Driver License Number and State
Social Security Number
Month, Day, and Year of Birth
Sex
Color of Eyes
Height
Weight
EMPLOYEE UNDERSTANDING: I understand that the National Driver Register (NDR) search will result in a printed report which will be
sent only to the employer or regulatory agency listed above on this form. The report will indicate either (1) that the NDR does not contain a
record matching my identification or (2) that the NDR has a probable identification (match) from one state (or more) which will be named on
the report. A separate check of state files would be required (1) to verify the identification or (2) to obtain the driving record. It is the
responsibility of the listed employer to obtain the state driver records and to determine or verify records which apply to me. Under the
Privacy Act, I have the right to request record(s) pertaining to me from the NDR. I also understand that if convictions, suspension or
revocations of mine are found which I have not shown on my applications or interviews, I might not be hired as a driver or could lose my job
as a driver, and the State where I am licensed may also take action on my driver license including suspension, cancellation, or revocation. I
hereby, with my signature, authorize a one-time file search of the NDR and any resulting reports to be sent to the employer or agency named
on this form.
Driver's Signature (Please read information on back before signing.)
Date
NOTARIZATION
Official Use Only
Required only if the NDR File Check is not made in person by the
current or prospective operator.
Date Received
Date Sent
Internal Control
Sworn to and ascribed before me
Notary Public
Seal or Stamp
this __________ day of ___________________
19__________ in the city/county of
______________________________________
State of _______________________________
TYPE OF IDENTIFICATION: z Valid Photo Driver License z State-issued Photo ID
DO NOT WRITE IN THIS SPACE - DEPT. USE ONLY!
zBirth Certificate z Valid Passport z Valid Military ID z Military Discharge Papers
z Other (specify) ______________________________________________________
Employee Verifying Applicant Identification (Print Name)
Signature
TA-VN-191 .5M 11/95 JTB
Comment = "PDPS INQUIRY SENT _________________"
(MM/DD/YY)
See Reverse Side for Additional Explanations
Requests for National Driver Register (NDR) Record Checks
Who May Obtain an NDR Record Check
Any person may ask to know whether there is an NDR record on him or her and may obtain a copy of
the record if one exists. Requests from individuals require Form NDR-PRV. (Vermont form TA-VN-192)
Employers of drivers and locomotive engineers may also obtain NDR record checks. Every driver or
operator on whom an NDR file check is requested is entitled to review the NDR report(s) provided to the
employer. The results of the NDR check will be mailed only to the current or prospective employer. If no
employer is named on the form or it is changed, the request will not be processed.
The following authorization applies to Railroad Company Requests
NDR CHECK AUTHORIZATION: The U.S. Department of Transportation, Federal Railroad Administration, in
accordance with 49 CFR, Part 240.111, required that I hereby request and authorize the National Highway Traffic
Safety Administration (NHTSA) to perform an NDR check of my driving record for 36-month period prior to the
date of this request including license withdrawal actions effective during that period. I hereby authorize the NDR
to furnish a copy of the results of this NDR check directly to the railroad company identified on this inquiry form.
What NDR Records Contain
NDR results for employers will contain only the identification of the state(s) which have reported
information on the driver to the NDR and only information reported within the past 3 years from the date of the
inquiry. Driver control actions initiated prior to that time, even if still in effect, will not be included.
Detailed information to confirm identity or to describe the contents of the driver record can be obtained
only from the State(s) listed when probable matches are reported. The name and address of the driver licensing
official will be provided for each state listed.
How to Request an NDR Record Check
Using this form, which may be completed by either the current or prospective employer or the current or
prospective employee, (1) the driver must authorize the request by his or her signature or make as witnessed and
(2) the driver must certify his or her identity.
Any mailed NDR record check request must be notarized to certify identity. Requests made in person
require certification of identity acceptable to the state through one or more documents issued by a recognized
organization (e.g., a driver's license or a credit card) which contains a means of verification such as a
photograph or a signature.
Location of NDR Records
Records on individuals can be made available to those individuals, within a reasonable time after
request, for personal inspection and copying during regular working hours at 7:45 a.m. to 4:15 p.m., each day
except Saturdays, Sundays and Federal legal holidays. The address for requesting record information in writing
directly from the NDR or for making requests in person is ---
National Driver Register
Nassif Building
400 7th Street, S.W.
Washington, DC 20590
Page of 2