Pull Notice Program Enrollment / No-Drive Provision Declaration

Pull Notice Program Enrollment / No-Drive Provision Declaration

Send Completed Form by Inter-Office Mail to “EPN - Labor & Employee Relations, 550 Bldg”

Please Review Policy #450.08 – Employee Qualification To Drive Motor Vehicles.

Check Only One Option.

Option A: I request to drive a motor vehicle under Policy #450.08. Enroll me in the Pull Notice Program.

Complete the “Authorization of Release of Driver Record Information” section. Complete

and sign the “Personal Information & Signature” section.

Option B: I elect the No-Drive Provision. I hereby declare that I will not drive an Authority owned or

leased motor vehicle or drive a privately owned motor vehicle as described in Policy #450.08.

Complete and sign only the “Personal Information & Signature” section.

Option A Only - Authorization of Release of Driver Record Information

I hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving record, to my employer, the

Orange County Transportation Authority.

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 the 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 eligibility as a licensed driver for my employment.

Enter Your California Driver License # Here:

Personal Information & Signature

First Name: _____________________________Last Name: ______________________________________

Badge#: __________ Job Title: _____________________________________________________________

Supervisor: ______________________________ Department: ____________________________________

Executed at the City of: ______________________ County of: _________________ State: ____________

Your Signature: _________________________________________________ Date: ___________________

DO NOT WRITE IN THIS BOX

I do hereby certify under penalty of perjury under the laws in the State of California, that I am an authorized representative of the Orange County Transportation Authority, 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 the Orange County Transportation Authority 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 of Orange, County of Orange, State of California

EPN Program Coordinator Signature:____________________________________________Date:__________________

Equivalent to DMV INF 1101 / Revised 01/2011

Available to DMV Staff Upon Request