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Department of Motor Vehicles
Employer Pull Notice Program (EPN)

AS ADMINISTERED BY THE CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
DEPARTMENT OF POLICE SERVICES

IMAGE OF POLICE DEPARTMENT SHIELD
ENROLLMENT FORM/APPLICATION TO OPERATE STATE VEHICLE & DMV RECORD RELEASE
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EMPLOYEES WHO 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:
1.
 POSSESS AND MAINTAIN A VALID CALIFORNIA DRIVERS LICENSE (FOREIGN LICENSES ARE NOT PERMITTED). THE DRIVERS LICENSE MUST BE APPROPRIATE FOR THE JOB AND VEHICLE(S) TO BE OPERATED. (i.e. class A, B, C)
2.
 NOT HAVE RECEIVED MORE THAN THREE MOVING VIOLATIONS AND/OR ACCIDENTS OR COMBINATION THEREOF IN THE PAST TWELVE-MONTH PERIOD (IN ACCORDANCE WITH THE CSU VEHICLE USE POLICY.
3.
 COMPLETE THE CSU APPROVED DEFENSIVE DRIVING COURSE. CLASSROOM AND ONLINE TRAINING AVAILABLE BY CALLING THE ENVIRONMENTAL HEALTH & SAFETY OFFICE AT X2401. COMPLETION OF THE DDC IS REQUIRED EVERY FOUR YEARS.
4.
 ENROLL IN THE UNIVERSITY'S DEPARTMENT OF MOTOR VEHICLES EMPLOYER PULL-NOTICE PROGRAM.
5.
 HAVE AND MAINTAIN A GOOD AND SAFE DRIVING RECORD. THE DEPARTMENT OF PUBLIC SAFETY WILL REVIEW THE INITIAL DRIVERS LICENSE MOTOR VEHICLE RECORD FROM THE DMV.
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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:
FIRST NAME: MIDDLE: LAST:
CA DRIVERS LIC #: LICENSE CLASS: EXP. DATE:
DATE OF BIRTH: CSUN EMPLOYEE ID: PHONE:
JOB TITLE: DEPARTMENT: PHONE:
• ARE YOU A (CHECK ONE):    STATE EMPLOYEE STUDENT ASSISTANT VOLUNTEER
• Have you completed a State approved Defensive Driving Course within the last four years? YES NO
• Do you ever drive your private vehicle on State business? YES NO If YES, please submit form STD-261*
* (AUTHORIZATION TO USE PRIVATELY OWNED VEHICLE ON STATE BUSINESS)
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RELEASE: I UNDERSTAND THAT BY SIGNING THIS FORM I AM ENROLLING IN THE DMV PULL NOTICE PROGRAM. I UNDERSTAND AND AGREE THAT I MUST POSSESS AND MAINTAIN A VALID STATE DRIVERS 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 DRIVERS LICENSE AND A SAFE DRIVING RECORD. I HEREBY AUTHORIZE THE UNIVERSITY TO OBTAIN MY DRIVERS 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 AND 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 DRIVERS LICENSE. I CERTIFY THAT I HAVE NOT BEEN ISSUED MORE THAN THREE MOVING VIOLATIONS OR HAVE BEEN INVOLVED IN MORE THAN THREE MOTOR VEHICLE ACCIDENTS (OR ANY COMBINATION OF MORE THAN THREE THEREOF) DURING THE PAST TWELVE MONTH PERIOD.
Employee Signature: ____________________________ Date: _______

Authorized by:

Manager/Dean/Director Signature: _________________

 

Date: _______

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