PrintUCLA 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