Inf1100 Form – Fill Out and Use This PDF

All Employer Pull Notice (EPN) applicants must complete this enrollment form in its entirety to avoid processing delays, and pay the required $5 fee for each enrolled driver. Checks must be made out to the California Department of Motor Vehicles (DMV) and submitted with this enrollment form. An original signature is required from the Authorized Representative. Select only one option per form. Enrollments, deletions, and changes to remarks must be submitted on separate forms. The enrollment form must be completed clearly in ink, by typewriter, or online then printed, and mailed to the address below.

Any changes made to the EPN account (e.g. mailing address or contact information) must be submitted to EPN on a Notice of Change form (INF 4).

SECTION 1 — EMPLOYER INFORMATION

•Company Legal Name/Sole Proprietor Name: List the legal name of the company or sole proprietor.

•Mailing Address: Provide the company’s full mailing address with city, state, and zip code on the EPN account.

•Requester Code: Provide assigned EPN Requester Code issued by the DMV (if no Requester Code assigned yet leave blank). Incorrect Requester Codes will cause rejection of the enrollment form.

•Telephone Number: Provide the business telephone number.

•Contact Person(s): Person(s) within the company who can contact EPN regarding the company’s EPN account.

SECTION 2 — DRIVER INFORMATION

•California Driver License or “X” Number: Provide the complete CA DL Number, or the “X” number assigned to the driver by CA.

•Driver’s Full Last Name Only: Provide the true full legal last name as it appears on the driver’s DL.

•Change Remarks: Place an X next to the driver information, when requesting a change be made to the remarks currently on file.

•“Remarks” Column: Optional field for employers to add information to the Driver Record Report (DL 414), for

example: terminal site, vehicle plate/VIN number, employee identification number, or out-of-state driver license number.

Note: Driver’s name, Date of Birth, or Social Security Numbers will not be keyed. (Maximum 21 characters)

•Total for Added/Deleted Drivers: Provide the total number of drivers added/deleted on the form.

Note: Enrollments and deletions must be submitted on separate forms. The form will be returned unprocessed if both are submitted on the same form.

•$5 Due for Each Driver Enrolled: Attach a check or money order to the form. Checks must be made out to the CA DMV.

Note: All subsequent invoices for this account will be sent to the company billing address on file with the Automated Billing Information Services (ABIS) unit. If you have any questions, please call (916) 657-6346.

SECTION 3 — CERTIFICATION (ORIGINAL SIGNATURE REQUIRED)

•Printed Name: The printed name of the Authorized Representative signing the form; must be the individual within the company who is responsible for managing the EPN account.

•Date: Provide date the enrollment form is being signed.

•Original Signature Required: This section must be signed by the Authorized Representative.

A Driver Record Report (DL 414) will be generated and mailed to the employer within ten (10) business days from the date of enrollment for newly enrolled drivers, and upon action/activity or annually for currently enrolled drivers. An employer may also request a copy of a driver record for a prospective hire or casual driver by submitting a Request for Driver License/

Identification Card Status and Record Information (INF 1119). There is a $5 fee for each driver request. This request must be submitted to the California Department of Motor Vehicles, Information Release Unit, MS G199 P.O. Box 944247, Sacramento, CA 94244. Original signature is required. For additional information regarding alternative available options for requesting printouts (e.g. Service Providers or Electronic Secure File Transfer), please call the EPN unit (916) 657-6346.

INF 1100 (REV. 8/2018) WWW

SECTION 3 — CERTIFICATION (ORIGINAL SIGNATURE REQUIRED) Continued

Note: It is the employer’s responsibility to delete enrolled drivers immediately upon termination of employment. DMV information may not be shared, and must be used in accordance with California Vehicle Code §1808.1. Business entities

are responsible for destroying DMV record information containing personal information, such as name, driver license or identification number, or physical characteristics, etc. no longer required for their business purposes by shredding, erasing, or modifying the personal information to make it unreadable or undecipherable as provided in Civil Code §§1798.80, 1798.81, and 1798.82.

For processing time, please allow up to thirty (30) days from the date the application is received in the unit. Keep a copy of the completed form for your records.

Please mail the completed form(s) with original signature and related fees to:

Mailing Address:	Overnight Address:
Department of Motor Vehicles	Department of Motor Vehicles
EPN Program - H265	EPN Program - H265
P.O. Box 944231	2415 First Avenue
Sacramento, CA 94244-2310	Sacramento, CA 95818

INF 1100 (REV. 8/2018) WWW

PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM.

CHECK ONLY ONE PROCESS PER FORM

ENROLL DELETE CHANGE REMARKS

Instructions:Pleasetypeorprintinink.Enrollments,deletions,andchangestoremarksmustbesubmittedonseparate forms. Any changes made to the EPN account (e.g. mailing address or contact information) must be submitted to EPN on a Notice of Change form (INF 4).

SECTION 1 — EMPLOYER INFORMATION

MAILING ADDRESS

CITY

STATE

ZIP CODE

CALIFORNIA DRIVER LICENSE OR	DRIVER	CHANGE	“REMARKS” FOR YOUR USE (OPTIONAL)
“X” NUMBER	FULL LAST NAME ONLY	REMARKS	(MAX 21 CHARACTERS)

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

Total Drivers Added ($5 Enrollment Fee due for each driver added)

Total Drivers Deleted (No Fee)

SECTION 3 — CERTIFICATION (ORIGINAL SIGNATURE REQUIRED)

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. The driver(s) listed above are (1) mandated for enrollment under California Vehicle Code §1808.1. OR (2) have signed an Authorization for Release of Driver Record Information form (INF 1101).

PRINTED NAME

To obtain additional forms and information please visit our website at: www.dmv.ca.gov

INF 1100 (REV. 8/2018) WWW