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Request From Record Holder: Missouri Department of Revenue Motor Vehicle and Driver Licensing Division
Request From Record Holder: Missouri Department of Revenue Motor Vehicle and Driver Licensing Division
06-24-69
I further certify that my date of birth is _________________, 493-82-9211
that my Missouri driver license number is ___________________,
(Month/Day/Year)
6 ___
and that my daytime telephone number is (___ 6 ___)
1 ___
6 ___
2 ___
3 - ___
3 ___
2 ___
5 ___
2 .
(Include Area Code)
If you are paying by credit/debit card you must provide the following:
NAME (AS IT APPEARS ON CARD) CARD TYPE CARD NUMBER EXPIRATION DATE
__ __ / __ __
I hereby authorize the Missouri Department of Revenue to fax ✔ mail this record information to:
Barbara J. (Brush) Pierce
Name: ___________________________________________ Fax: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
__ __ / __ __ / __ __ __ __
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER OR STATE COUNTY (OR CITY OF ST. LOUIS)
BLACK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF YEAR
NOTARY PUBLIC SIGNATURE MY COMMISSION
EXPIRES
THE MISSOURI DEPARTMENT OF REVENUE MAY ELECTRONICALLY RESUBMIT CHECKS RETURNED FOR INSUFFICIENT OR UNCOLLECTED FUNDS
MO 860-2768 (09-2009) DOR-4681 (09-2009)