California DMV Employer Pull Notice (EPN) Authorization for Release of Driver Record Information - INF 1101

Sep 20, 2026

Upload by Eliana

Authorization form for a California public service agency employer pull notice program. The employee grants the California Department of Motor Vehicles (DMV) permission to disclose driving record information to the employer. The agreement explains the employer’s potential enrollment in the Employer Pull Notice (EPN) program at least annually or upon specified convictions or actions, and states how the record will be used for eligibility verification. The document includes certification by an authorized company representative and confidentiality and penalty acknowledgements, with form requirements for submission and retention.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Authorization for Release of Driver Record Information

Employee authorization (EPN program)

Authorized representative certification

Form use and submission instructions

A Public Service Agency 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, COMPANY NAME 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, 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. EXECUTED AT: CITY COUNTY STATE | DATE | SIGNATURE OF EMPLOYEE
X | | --- | --- | | I, , of
AUTHORIZED REPRESENTATIVE COMPANY NAME
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 Iam 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 AND TITLE OF AUTHORIZED REPRESENTATIVE
X | 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](at www.dmv.ca.gov/otherservices), or by calling 916-657-6346 . THIS FORM MUST bE COMPLETED AND retained at the employer’s principal place of business and MADE AVAILAbLE UPON REqUEST TO DMV STAFF. DO not RETURN THIS FORM TO DMV. INF 1101 ENGLISH (REV. 9/2004) Clear Form Print

FAQs

What does the employee authorize the California DMV to do?

The employee authorizes the California Department of Motor Vehicles (DMV) to disclose or make available the employee’s driving record information to the employer.

When may the employer receive the driver record report under the EPN program?

The employer may receive a driver record report at least once every twelve (12) months, or when a subsequent conviction, failure to appear, accident, or suspension or revocation affects the employee’s driving privilege during employment.

Who must certify the company information and what are the consequences for false information?

An authorized representative must certify the entered information and the business need to verify the individual. The form states that providing false information may lead to prosecution for perjury and false representation, and confidentiality failures may lead to civil and criminal penalties.

Sep 20, 2026

Upload by Eliana