Form NDR-EMP (DPSMV2020) "Request for National Driver Register File Check on Current or Prospective Employee" - Louisiana

What Is Form NDR-EMP (DPSMV2020)?

This is a legal form that was released by the Louisiana Department of Public Safety & Corrections - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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Download a fillable version of Form NDR-EMP (DPSMV2020) by clicking the link below or browse more documents and templates provided by the Louisiana Department of Public Safety & Corrections.

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Download Form NDR-EMP (DPSMV2020) "Request for National Driver Register File Check on Current or Prospective Employee" - Louisiana

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REQUEST FOR NATIONAL DRIVER REGISTER FILE CHECK ON CURRENT OR PROSPECTIVE EMPLOYEE
Current or Prospective Employer to Receive the NDR Search Results:
Driver Employer
Railroad Company
Employer or Agency Name:
To the specific attention of:
Business Telephone
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
Home Telephone
(Optional)
and Box Number)
City, State and Zip Code
Work Telephone
(Optional)
Driver License Number and State (Driver must be licensed in the State initiating the search)
Social Security #
(Optional)
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 that 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, suspensions 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 the next page before signing)
Date
NOTARIZATION
OFFICIAL USE ONLY
Required only if the NDR File Check Request is not made
in person by the current or prospective operator
Date Received
Date Sent
Internal Control
Sworn and ascribed before me this
Notary Public
Seal or Stamp
________________________ day of
TYPE OF IDENTIFICATION:
___________________, ________ in
Birth Certificate
Valid Photo Driver License
the city/county of _______________
Valid Passport
State-Issued Photo ID
______________________________
Military Discharge Papers
Valid Military ID
State of _______________________
Other (Specify)
Signature
Employee Verifying Applicant Identification (Print Name)
SEE NEXT PAGE FOR ADDITIONAL EXPLANATIONS
FORM NDR-EMP
DPSMV 2020
REQUEST FOR NATIONAL DRIVER REGISTER FILE CHECK ON CURRENT OR PROSPECTIVE EMPLOYEE
Current or Prospective Employer to Receive the NDR Search Results:
Driver Employer
Railroad Company
Employer or Agency Name:
To the specific attention of:
Business Telephone
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
Home Telephone
(Optional)
and Box Number)
City, State and Zip Code
Work Telephone
(Optional)
Driver License Number and State (Driver must be licensed in the State initiating the search)
Social Security #
(Optional)
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 that 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, suspensions 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 the next page before signing)
Date
NOTARIZATION
OFFICIAL USE ONLY
Required only if the NDR File Check Request is not made
in person by the current or prospective operator
Date Received
Date Sent
Internal Control
Sworn and ascribed before me this
Notary Public
Seal or Stamp
________________________ day of
TYPE OF IDENTIFICATION:
___________________, ________ in
Birth Certificate
Valid Photo Driver License
the city/county of _______________
Valid Passport
State-Issued Photo ID
______________________________
Military Discharge Papers
Valid Military ID
State of _______________________
Other (Specify)
Signature
Employee Verifying Applicant Identification (Print Name)
SEE NEXT PAGE FOR ADDITIONAL EXPLANATIONS
FORM NDR-EMP
DPSMV 2020
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 exits.
Requests from individuals require Form NDR-PRV.
Employers of drivers and locomotive engineers may also obtain NDR record checks. Employer/Employee request require Form
NDR-EMP. 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 or third party service provider. 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, requires that I hereby request and authorize the National Highway Traffic Safety
Administration (NHTSA) to perform an NDR check of my driver record for a 36-month period to the date of this request
including license withdrawal actions open at time of file check. I hereby authorize the NDR to furnish a copy of the
results of this NDR check directly to the railroad company identifies 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 injury. 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 (NDR-EMP), which may be completed by either the current or prospective employer on the current or prospective
employee, (1) the driver must authorize the request by his or her signature or mark 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.
Request must be made to the state where the driver is licensed.
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
th
400 7
Street, S.W.
Washington, DC 20590
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