Fillable Printable Form 4684 - Missouri Department Of Revenue
Fillable Printable Form 4684 - Missouri Department Of Revenue
Form 4684 - Missouri Department Of Revenue
Name of Company or Corporation Contact Person
Missouri Department of Revenue
Notice of Failure to Pass a Drug, Alcohol, or Chemical Test
Regarding Persons Possessing School Bus Endorsements
Form
4684
Form 4684 (Revised 03-2014)
Mail to: Driver License Bureau Phone: (573) 526-2407
P.O. Box 200 Fax: (573) 751-0466
Jefferson City, MO 65105-0200 E-mail: dlbmail@dor.mo.gov
Visit http:// dor.mo.gov//faq/drivers
for additional information.
I certify that on ___ ___ / ___ ___ / ___ ___ ___ ___ , the above employee:
r Failed to Pass r Refused to Complete a(n):
r Drug Test
r Alcohol Test Administered By: __________________________________________________________
r Chemical Test
All tests were administered pursuant to the requirements of any federal or state law, rule, or regulation regarding
the operation of a school bus.
Employee Information
Certification
Signature of Employer or Officer of Employer Title
Printed Name Date (MM/DD/YYYY)
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Employer
Information
City State Zip Code
Address Telephone Number
Driver License Number Date of Birth (MM/DD/YYYY)
First Name Middle Initial Last Name
_____ _____ / _____ _____ / _____ _____ _____ _____
Address
City State Zip Code
Signature
Enclose a copy of all test results with this form to the address listed below.
(____ ____ ____) ____ ____ ____ - ____ ____ ____ ____
_____ _____ / _____ _____ / _____ _____ _____ _____
(MM/DD/YYYY)
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