Form INF1102 "Commercial or Government Employer Pull Notice Enrollment of out-Of-State Licensed Drivers" - California

What Is Form INF1102?

This is a legal form that was released by the California Department of Motor Vehicles - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the California Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form INF1102 by clicking the link below or browse more documents and templates provided by the California Department of Motor Vehicles.

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Download Form INF1102 "Commercial or Government Employer Pull Notice Enrollment of out-Of-State Licensed Drivers" - California

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STATE OF CALIFORNIA
COMMERCIAL OR GOVERNMENT EMPLOYER PULL NOTICE
ENROLLMENT OF OUT-OF-STATE LICENSED DRIVERS (INF 1102)
®
DEPARTMENT OF MOTOR VEHICLES
A Public Service Agency
INSTRUCTIONS
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 on a Commercial EPN account. 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. This form is to be used solely for the purpose of enrolling drivers with an out-of-state license
into the EPN program. A copy of the out-of-state driver license must be attached for all enrollments. 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/Agency Name/Sole Proprietor Name: List the legal name of the company, agency name, or
sole proprietor.
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.
Mailing Address: Provide the agency/company’s full mailing address with city, state, and zip code on the EPN account.
Contact Person(s): Person(s) within the company/agency who can contact EPN regarding the company’s EPN account.
Telephone Number: Provide the business telephone number.
SECTION 2 — DRIVER INFORMATION
(UP TO 4 DRIVERS MAY BE ADDED PER FORM)
Full Legal Name: Provide the driver’s complete legal name (last, first, and middle name) as it appears on their DL. (Do
not use initials. If no middle name you must enter “NMN”.)
Date of Birth: Month, day, and year driver was born. (e.g. 01/12/1962)
Home State Address: Driver’s home state address, including city, state and zip code. (Must not be a CA address)
Out-of-State Driver License Number: Provide the complete DL Number issued to the driver from their home state.
Note: If the driver has a previously issued CA DL Number, or “X” number, please complete INF 1100 form.
Issuing State: Provide the state where the out-of-state DL was issued.
Remarks: Optional field for employers to add information to the Driver Record Report (DL 414), for example: terminal
site, vehicle plate/VIN, employee identification number, or out-of-state DL Number.
Note: Driver’s name, DOB, or Social Security Numbers will not be keyed. (Maximum 21 characters)
$5 Due for Each New Driver Enrolled on a Commercial EPN Account: 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/agency who is responsible for managing the EPN account.
Original Signature Required: This section must be signed by the Authorized Representative.
Date: Provide date the enrollment form is being signed.
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 Commercial EPN Account
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.
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INF 1102 (REV. 7/2018) WWW
STATE OF CALIFORNIA
COMMERCIAL OR GOVERNMENT EMPLOYER PULL NOTICE
ENROLLMENT OF OUT-OF-STATE LICENSED DRIVERS (INF 1102)
®
DEPARTMENT OF MOTOR VEHICLES
A Public Service Agency
INSTRUCTIONS
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 on a Commercial EPN account. 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. This form is to be used solely for the purpose of enrolling drivers with an out-of-state license
into the EPN program. A copy of the out-of-state driver license must be attached for all enrollments. 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/Agency Name/Sole Proprietor Name: List the legal name of the company, agency name, or
sole proprietor.
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.
Mailing Address: Provide the agency/company’s full mailing address with city, state, and zip code on the EPN account.
Contact Person(s): Person(s) within the company/agency who can contact EPN regarding the company’s EPN account.
Telephone Number: Provide the business telephone number.
SECTION 2 — DRIVER INFORMATION
(UP TO 4 DRIVERS MAY BE ADDED PER FORM)
Full Legal Name: Provide the driver’s complete legal name (last, first, and middle name) as it appears on their DL. (Do
not use initials. If no middle name you must enter “NMN”.)
Date of Birth: Month, day, and year driver was born. (e.g. 01/12/1962)
Home State Address: Driver’s home state address, including city, state and zip code. (Must not be a CA address)
Out-of-State Driver License Number: Provide the complete DL Number issued to the driver from their home state.
Note: If the driver has a previously issued CA DL Number, or “X” number, please complete INF 1100 form.
Issuing State: Provide the state where the out-of-state DL was issued.
Remarks: Optional field for employers to add information to the Driver Record Report (DL 414), for example: terminal
site, vehicle plate/VIN, employee identification number, or out-of-state DL Number.
Note: Driver’s name, DOB, or Social Security Numbers will not be keyed. (Maximum 21 characters)
$5 Due for Each New Driver Enrolled on a Commercial EPN Account: 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/agency who is responsible for managing the EPN account.
Original Signature Required: This section must be signed by the Authorized Representative.
Date: Provide date the enrollment form is being signed.
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 Commercial EPN Account
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.
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INF 1102 (REV. 7/2018) WWW
SECTION 3 — CERTIFICATION
Continued
(ORIGINAL SIGNATURE REQUIRED)
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 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
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INF 1102 (REV. 7/2018) WWW
COMMERCIAL OR GOVERNMENT EMPLOYER PULL NOTICE
Department of Motor Vehicles
STATE OF CALIFORNIA
Office of Information Services
ENROLLMENT OF OUT-OF-STATE LICENSED DRIVERS
Employer Pull Notice-H265
P.O. Box 944231
®
DEPARTMENT OF MOTOR VEHICLES
(FOR ENROLLMENTS ONLY)
A Public Service Agency
Sacramento, CA 94244-2310
PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM.
Instructions: Please type or print in ink. Form will not be processed if incomplete or missing information. 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).
NOTE: COPY OF OUT-OF-STATE DRIVER LICENSE MUST BE ATTACHED FOR ALL ENROLLMENTS TO
ENSURE ACCURATE PROCESSING.
SECTION 1 — EMPLOYER INFORMATION
COMPANY LEGAL NAME / AGENCY NAME / SOLE PROPRIETOR NAME
REQUESTER CODE
MAILING ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON (NAME AND TITLE)
TELEPHONE
EXT
(
)
SECTION 2 — DRIVER INFORMATION
(PRINT AS SHOWN ON OUT-OF-STATE LICENSE)
1. FULL LEGAL NAME – LAST, FIRST, MIDDLE (IF NO MIDDLE NAME ENTER “NMN”)
DATE OF BIRTH
HOME STATE ADDRESS
CITY
STATE
ZIP CODE
OUT-OF-STATE DRIVER LICENSE NUMBER
ISSUING STATE
OPTIONAL REMARKS (MAXIMUM 21 CHARACTERS)
2. FULL LEGAL NAME – LAST, FIRST, MIDDLE (IF NO MIDDLE NAME ENTER “NMN”)
DATE OF BIRTH
HOME STATE ADDRESS
CITY
STATE
ZIP CODE
OUT-OF-STATE DRIVER LICENSE NUMBER
ISSUING STATE
OPTIONAL REMARKS (MAXIMUM 21 CHARACTERS)
3. FULL LEGAL NAME – LAST, FIRST, MIDDLE (IF NO MIDDLE NAME ENTER “NMN”)
DATE OF BIRTH
HOME STATE ADDRESS
CITY
STATE
ZIP CODE
OUT-OF-STATE DRIVER LICENSE NUMBER
ISSUING STATE
OPTIONAL REMARKS (MAXIMUM 21 CHARACTERS)
4. FULL LEGAL NAME – LAST, FIRST, MIDDLE (IF NO MIDDLE NAME ENTER “NMN”)
DATE OF BIRTH
HOME STATE ADDRESS
CITY
STATE
ZIP CODE
OUT-OF-STATE DRIVER LICENSE NUMBER
ISSUING STATE
OPTIONAL REMARKS (MAXIMUM 21 CHARACTERS)
$5 ENROLLMENT FEE DUE FOR EACH DRIVER ENROLLED ON A COMMERCIAL EPN ACCOUNT
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).
PRINT NAME AND TITLE
SIGNATURE
DATE
X
To obtain additional forms and information please visit our website at: www.dmv.ca.gov
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INF 1102 (REV. 7/2018) WWW
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