UCLA

UCLA EMPLOYER PULL NOTICE (EPN) PROGRAM ADD, DELETE, UPDATE FORM

Instructions: Complete this form and attach a photocopy of the employee’s driver's license. Once completed, provide the form to your department's designated R.I.D.E. Department Contact. The Department Contact will use the information to enroll the driver in the DMV Pull Notice Program through the R.I.D.E. system.

After the driver has been enrolled, the completed form and driver's license copy should be retained in the employee's departmental personnel file or forwarded to Campus Human Resources (CHR) for inclusion in the employee's official personnel file, in accordance with departmental recordkeeping practices.

__ Add to Pull Notice

__ Delete from Pull Notice

__ Change 

                                

From _____________________   Dept. Code: _______________

 

 To ________________________ Dept. Code: _______________

 

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Name of Employee: (First)________________(Middle)________________ (Last)________________

Driver's License Number:________________ Exp. Date: ________________DOB________________

 

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License State: ____________ License Zip Code: _________

Class of License:____________ Endorsement: ____________Medical Card Exp. Date:____________

University ID: _________________Title Code: ____________ Payroll Title:____________

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Department Information

Department:                                 Dept. Code:

Department Contact Name:         Phone #

Manager/Supervisor Name:

Manager/Supervisor Signature:   Date:

Date Added to RIDE:____________________           Date Removed From RIDE:___________________