Fillable Form Inf 1101 - Authorization For Release Of Driver Record Information printable pdf download

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,_______________________________________________________________________________

UC San Diego Sports Clubs

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

La Jolla

San Diego

DATE

SIGNATURE OF EMPLOYEE

I, ______________________________________________ , of _________________________________________________

Liz Henry

UC San Diego Sports Clubs

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 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

La Jolla

San Diego

DATE

SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE

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 , 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.

Clear Form

INF 1101 ENGLISH (REV. 9/2004) WWW

Form Inf 1101 - Authorization For Release Of Driver Record Information

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