Pull Notice 2015
EMPLOYER PULL NOTICE PROGRAM
2014-15 FISCAL YEAR
AUTHORIZATION FOR RELEASE OF DRIVER RECORD INFORMATION
, California Driver’s License Number
Print your full name as it appears on your Driver’s License
hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make
available, my driving record, to my employer, Yosemite Community College District (YCCD).
I understand th
at in order to be approved to drive a District vehicle for District business, YCCD will
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, driver’s
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.
______________________________________________ ____________________________
Employee Signature Date
Do Not Write Below This Line.
I, Jim Codoni, an employee of Yosemite Community College District, 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 1080.1. 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 in the City of Modesto, County of Stanislaus, State of California.
__Jim Codoni________________________________________ _______________________________
Signature of YCCD authorized representative Jim Codoni Date
THIS FORM MUST BE COMPLETED AND RETAINED AT THE EMPLOYER’S PRINCIPLE PLACE OF
BUSINESS AND MADE AVAILABLE UPON REQUEST TO DMV STAFF.
Return form with original signatures and copy of your Driver’s License to
Jim Codoni, YCCD Transportation.
