Form TA-VN-192 "Individual's Request for National Driver Register (Ndr) File Check in Accordance With the Federal Privacy Act of 1974 (Public Law 93-579)" - Vermont

What Is Form TA-VN-192?

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-192 by clicking the link below or browse more documents and templates provided by the Vermont Department of Motor Vehicles.

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Download Form TA-VN-192 "Individual's Request for National Driver Register (Ndr) File Check in Accordance With the Federal Privacy Act of 1974 (Public Law 93-579)" - Vermont

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STATE OF VERMONT
AGENCY OF TRANSPORTATION
DEPARTMENT OF MOTOR VEHICLES
120 State Street, Montpelier, VT 05603-0001
Individual's Request for National Driver Register (NDR) File Check
in Accordance with the Federal Privacy Act of 1974 (Public Law 93-579)
The National Driver Register (NDR) contains only a listing of names and related identification, provided by State driver
licensing officials, of those drivers whose driver licenses have been canceled, denied, revoked, or suspended or who have been
convicted of certain serious traffic violations. The NDR does not contain a list of any other drivers. If you have not had a driver
license canceled, denied, revoked, or suspended or have not been convicted of serious traffic violations, you would not be listed
in the NDR. Every individual is entitled, however, to request a check of the NDR records to determine whether they appear on
the NDR file. The NDR will respond to every valid NDR inquiry.
The record content for those persons who are listed in the NDR files is limited to identification of the state(s) which have taken
action to cancel, deny, revoke, or suspend or have records of conviction of serious traffic violations. 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 pointer records when so advised by a state indicating that a report previously made to the NDR is in error.
If the NDR has a record on you, the full record will be copied and sent to you including any older records which may have
contained a reason for license cancellation, denial, revocation, or suspension. In addition, if such information has been disclosed
by the NDR, the recipient of the information will also be identified.
The name and address of the State driver licensing official will be provided for each State listed as having reported information
on you to the NDR.
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
(Optional)
Month, Day, and Year of Birth
Sex
Color of Eyes
Height
Weight
Driver's Signature
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
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-192 .5M 11/95 JTB
See Reverse Side for Additional Explanations
STATE OF VERMONT
AGENCY OF TRANSPORTATION
DEPARTMENT OF MOTOR VEHICLES
120 State Street, Montpelier, VT 05603-0001
Individual's Request for National Driver Register (NDR) File Check
in Accordance with the Federal Privacy Act of 1974 (Public Law 93-579)
The National Driver Register (NDR) contains only a listing of names and related identification, provided by State driver
licensing officials, of those drivers whose driver licenses have been canceled, denied, revoked, or suspended or who have been
convicted of certain serious traffic violations. The NDR does not contain a list of any other drivers. If you have not had a driver
license canceled, denied, revoked, or suspended or have not been convicted of serious traffic violations, you would not be listed
in the NDR. Every individual is entitled, however, to request a check of the NDR records to determine whether they appear on
the NDR file. The NDR will respond to every valid NDR inquiry.
The record content for those persons who are listed in the NDR files is limited to identification of the state(s) which have taken
action to cancel, deny, revoke, or suspend or have records of conviction of serious traffic violations. 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 pointer records when so advised by a state indicating that a report previously made to the NDR is in error.
If the NDR has a record on you, the full record will be copied and sent to you including any older records which may have
contained a reason for license cancellation, denial, revocation, or suspension. In addition, if such information has been disclosed
by the NDR, the recipient of the information will also be identified.
The name and address of the State driver licensing official will be provided for each State listed as having reported information
on you to the NDR.
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
(Optional)
Month, Day, and Year of Birth
Sex
Color of Eyes
Height
Weight
Driver's Signature
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
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-192 .5M 11/95 JTB
See Reverse Side for Additional Explanations
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
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