Out-of-State Driver’s License
Employer Pull Notice Addition Form
Department Name: **Dept. Budget #:
Supervisor Name: Phone Extension:
All Out-of-State students who will be driving Chapman University vehicles or who are regular drivers for Chapman
University will be required to complete this form along with the online Authorized Driver Request form
(https://webfarm.chapman.edu/AuthorizedDriverForm/Default.aspx) to be considered for approval. All such drivers
that will thereby be added to the Employer Pull Notice Program must read the following paragraph and complete
the Authorization for Release of Information form (Page 2) to be considered for approval.
By providing the following information and signing your name on the Authorization for Release of Information Form you
agree to be placed in the Chapman University Employer Pull Notice Program for the purpose of determining your eligibility
for driving privileges and coverage under Chapman University’s business automobile insurance policy. Please note, as part
of the Pull-Notice Program, Chapman University will be notified by the California Department of Motor Vehicles if the
following actions are added to your driving record: Convictions, Failures to Appear, Accidents, Driver’s License
Suspensions, Driver’s License Revocations and any other actions taken against your driving privilege.
If any of these actions appear on your record, you may not be cleared as a driver. If at any point the university receives
notice of one of these actions being added to your driving record, your driving privileges may be revoked depending on
which action was added. Should you incur any of these actions, you must contact the Transportation Office within 48 hours.
Please note that drivers are required to be at least 21 years of age or have three years licensed driving experience.
By signing this form you acknowledge that as a further condition for securing and maintaining Authorized Driver status, it is
your personal responsibility to (1) report any violations to Chapman University and (2) present and maintain a valid driver’s
license from your state of legal residence and to comply with licensing and all other aspects of the California Vehicle Code.
LAST NAME, FIRST, MIDDLE (DO NOT USE INITIALS):
BIRTH DATE:
/ /
HOME STATE ADDRESS:
CITY:
STATE:
ZIP CODE:
DRIVER’S LICENSE NUMBER:
CLASS OF LICENSE:
**There is a processing fee for each Out-of-State driver seeking authorization. Fees vary by state and will be
charged to the department number (4 digit department code – 5 digit program code) listed on this form. Processing
cannot be completed without the department number.
For Official Use Only:
DMV: ____________
Online Training:
EPN:
Notify:
Please type or print the following information AND complete the Authorization for Release
of Information Form on the back (page 2) of this form.
Employer Pull Notice Program
Authorization for Release of Driver Record Information
I, ______________________________________, ________ Driver’s License Number ____________________________,
PRINT FIRST & LAST NAME STATE
hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving
record to my employer, _______________CHAPMAN UNIVERSITY____________.
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 the 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’s
license report will be released to my employer to determine my eligibility as a licensed driver for my employment.
EXECUTED AT: CITY
ORANGE
COUNTY:
ORANGE
STATE:
CA
DATE:
SIGNATURE OF EMPLOYEE:
X
I,__________________________________________________, of ____________CHAPMAN UNIVERSITY___________.
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 that 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
ORANGE
COUNTY:
ORANGE
STATE:
CA
DATE:
SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE:
X
To obtain a driver record on a prospective employee you may submit and INF 1119 form. To add this driver to the EPN
program you must submit the applicable forms: INF1100, INF1102, INF1103A form. You may obtain forms at our website 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.