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UCLA Procedure 615.1 : Attachment B

UCLA Employer Pull Notice (EPN) Program Add, Delete, Update Form

Instructions : Complete this form, include a photocopy of the employee's driver's license and mail it marked "Confidential" to the appropriate DMV Pull liaison office for your department (Campus: Transportation, Attn: DSC, 555 Westwood Plaza, mail code 135408; Medical Center: Medical Center Human Resources, 924 Westwood Blvd., Suite 200, mail code 166446; UCLA Police Department, 601 Westwood Plaza, mail code 136408).

(Type or print legibly in ink)

Please complete all sections below for enrollment in the EPN Program

[ ] Add to Pull Notice System


[ ] Delete from Pull Notice System

[ ] Change Department From____________ Recharge ID:____________ Dept. Code:____________

To____________     Recharge ID:____________ Dept. Code:____________

Employee Information

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

Driver's License Number:_______________________ Exp. Date:______________ DOB__________

Class of License:_________ Endorsement:______________ Medical Card Exp. Date:______________

University ID:____________________ Title Code:____________ Payroll Title:_________________________

**(Include a photocopy of the employee's driver's license)**

Department Information

Department:______________________________________________ Dept. Code:____________

Department Address:________________________________________ Mail Code:______________

Department Contact Name:___________________ Phone #:_____________ Fax#_______________

Department Recharge ID:____________ Recharge Acct./Fund:_______________________________

PO #_____________________________ Exp. Date____________________

Manager/Supervisor Name: ___________________________________________________

Manager/Supervisor Signature:____________________________________ Date:______________

DSC Coordinator Use Only

Date addition sent to DMV:                            Date deletion sent to DMV:

Rev. 5/2008