Enrollment Form/application To Operate State Vehicle & Dmv Record Release

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DEPARTMENT OF POLICE SERVICES

Employer Pull Notice Program (EPN)

(As Administered by the California State University, Northridge Department of Police Services)

ENROLLMENT FORM/APPLICATION TO OPERATE STATE VEHICLE & DMV RECORD RELEASE

Employees are required to operate motorized vehicles on University/State business are required to be safe drivers and operate

vehicles in a safe manner. This is your request to operate vehicles on University business. You must have your supervisor’s

permission to operate any vehicle on University business. If your position requires that you operate vehicles on University business,

then your continued employment may be contingent upon satisfying each of the following.

BEFORE OPERATING A VEHICLE ON UNIVERSITY/STATE BUSINESS, YOU MUST FIRST:

Possess and maintain a valid CA State Driver’s License (foreign licenses are not permitted). The driver’s license must be

appropriate for the job and vehicles to be operated, (i.e. , class A, B, C)

Not have received more than three moving violations and/or accidents or combination thereof in the past 12-month period

(in accordance with the

CSU Vehicle Use

Policy).

Complete the CSU approved Defensive Driving Course. Classroom training & online training are available by calling the

Environmental Health & Safety Office at x2401. Completion of the DDC is required every 4 years.

Enroll in the University’s Department of Motor Vehicles Employer Notice Program.

Have and maintain a good and safe driving record.

IN ORDER TO OPERATE VEHICLES ON UNIVERSITY BUSINESS, YOU MUST MAINTAIN A GOOD AND SAFE DRIVING RECORD. THE DMV

WILL PROVIDE THE UNIVERSITY WITH PERIODIC UPDATES OF YOUR DRIVING RECORD. TO INITIATE THE ENROLLMENT PROCESS,

PLEASE PROVIDE THE FOLLOWING:

Print Name: _________________________ _________________________ __________________________________

(First)

(Middle)

(Last)

CA Driver’s License #: _____________________ Class: _______________ Expiration Date: _____________

Date of Birth: ____________ CSUN Employee ID: ____________ Job Title: ____________________ Department: _______________

Are You A (Check One): State Employee

Student Assistant

Volunteer

Have your completed a state approved Defensive Driving Course within the last four (4) years?

YES

Do you ever drive your private vehicle on state business?

YES

If YES, please complete the

“Authorization to Use Privately Owned Vehicles on State

Business” form. Original to be retained your Supervisor.

RELEASE

I understand that by signing this form I am enrolling in the DMV Employer Pull Notice Program. I understand and agree that I must possess and

maintain a valid State Driver’s License in order to operate vehicles on University business. I further understand that if my job requires vehicle

operation, that my continued employment may be contingent upon maintaining a valid State Driver’s License and a safe driving record. I hereby

authorize the University to obtain my Driver’s License Information and review my DMV driving record for the purpose of verification of my right to

drive a motor vehicle on State business. I further acknowledge and agree that my supervisor or manager may be provided information relative to

my driving record. I hereby release and waive any claims that may be related to the use of this information with respect to my employment. I

certify that I am in possession of a valid California Driver’s License. I certify that I have not been issued more than three (3) moving violations or

have been involved in more than three (3) motor vehicle accidents, (or any combination of more than three thereof), during the past 12-month

period.

EMPLOYEE SIGNATURE: _____________________________ PRINT NAME: _______________________ DATE: _________________

I authorize the above-named employee to drive a University vehicle in the course and scope of their employment with CSUN.

MANAGER/DEAN/DIRECTOR SIGNATURE: _______________ PRINT NAME: _______________________ DATE: _________________

Send original copy to EPN Program Coordinator, Erika Breazile, Mail Drop 8282. Department please retain a copy for your records.