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\n\n| SECTION 1—DRIVER INFORMATION |  |  |\n| --- | --- | --- |\n| 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,  .\u003Cbr>COMPANY NAME\u003Cbr>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.\u003Cbr>I am not driving in a capacity that requires mandatory enrollment in the EPN program pursuant to California Vehicle Code (CVC) §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. |  |  |\n| EXECUTED AT: CITY COUNTY |  | STATE |\n| DATE | SIGNATURE OF EMPLOYEE\u003Cbr>X |  |\n| SECTION 2—AUTHORIZED REPRESENTATIVE CERTIFICATION |  |  |\n| I,   , of  \u003Cbr>AUTHORIZED REPRESENTATIVE COMPANY NAME\u003Cbr>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 §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 §118) and false representation (CVC §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 §§1808 .45 and 1808.46. |  |  |\n\n\n| DATE | SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE\u003Cbr>X |\n| --- | --- |\n|  |  |\n\nTo 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](at dmv.ca.gov/otherservices)[ dmv.ca.gov/otherservices](at dmv.ca.gov/otherservices), or by calling 916-657-6346 .  \nPLEASE RETAIN AT THE EMPLOYER’S PRINCIPAL PLACE OF BUSINESS AND  \nMAKE AVAILABLE UPON REQUEST TO DMV STAFF.  \nDO NOT RETURN THIS FORM TO DMV.  \nINF 1101 (REV. 5/2021) WWW  \nClear Form  \nPrint","cbCaijp3r9vZFP8i","https://ap.wps.com/l/cbCaijp3r9vZFP8i","pdf",455404,"English","# Section 1—Driver Information\n# Section 2—Authorized Representative Certification","[{\"question\":\"What does the employee authorize under the EPN program?\",\"answer\":\"The employee authorizes the California DMV to disclose the employee’s driving record to the employer.\"},{\"question\":\"How often may the employer receive a driver record report?\",\"answer\":\"The employer may receive a driver record report at least once every twelve months or when specified events occur during employment.\"},{\"question\":\"What legal consequences are mentioned for providing false information or breaching confidentiality?\",\"answer\":\"The document states that false information may lead to perjury prosecution and false representation charges, and that failure to maintain confidentiality is punishable civilly and criminally.\"}]","Employer Pull Notice Program - Authorization for Release of Driver Record Information | PDF",1789867746]