COMPANY NAME
AUTHORIZED REPRESENTATIVE COMPANY NAME
To obtain a driver record on a prospective employee you may submit an INF 1119 form. To add this driver to the EPN Program
you must submit the applicable forms: INF 1100, INF 1102, INF 1103, INF 1103A form. You may obtain forms at our website
at www.dmv.ca.gov/otherservices, or by calling 916-657-6346.
THIS FORM MUST BE COMPLETED AND RETAINED AT THE EMPLOYERS PRINCIPAL PLACE OF BUSINESS AND
MADE AVAILABLE UPON REQUEST TO DMV STAFF.
DO NOT RETURN THIS FORM TO DMV.
EMPLOYER PULL NOTICE PROGRAM
AUTHORIZATION FOR
RELEASE OF DRIVER RECORD INFORMATION
I, __________________________________________, California Driver License Number, ___________________________,
hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving
record, to my employer,_______________________________________________________________________________
I understand that my employer may enroll me in the Employer Pull Notice (EPN) program to receive a driver record report at
least once every twelve (12) months or when any subsequent conviction, failure to appear, accident, drivers license suspension,
revocation, or any other action is taken against my driving privilege during my employment.
I am not driving in a capacity that requires mandatory enrollment in the EPN program pursuant to California Vehicle Code
(CVC) Section 1808.1(k). I understand that enrollment in the EPN program is in an effort to promote driver safety, and that my
driver license report will be released to my employer to determine my eligibility as a licensed driver for my employment.
I, ______________________________________________ , of _________________________________________________
do hereby certify under penalty of perjury under the laws in the State of California, that I am an authorized representative of
this company, that the information entered on this document is true and correct, to the best of my knowledge and that I am
requesting driver record information on the above individual to verify the information as provided by said individual. This
record is to be used by this employer in the normal course of business and as a legitimate business need to verify information
relating to a driving position not mandated pursuant to CVC Section 1808.1. The information received will not be used for any
unlawful purpose. I understand that if I have provided false information, I may be subject to prosecution for perjury (Penal
Code Section 118) and false representation (CVC Section 1808.45). These are punishable by a fine not exceeding five
thousand dollars ($5,000) or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment. I
understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant to
CVC Sections 1808.45 and 1808.46.
EXECUTED AT: CITY COUNTY STATE
DATE SIGNATURE OF EMPLOYEE
EXECUTED AT: CITY COUNTY STATE
DATE SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE
X
X
A Public Service Agency
INF 1101 ENGLISH (REV. 9/2004) WWW
California State University Channel Islands
California State University Channel Islands
