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Get CA DMV Form INF 1104 EPN 2011

INFORMATION SERVICES BRANCH A Public Service Agency EMPLOYER PULL NOTICE PROGRAM APPLICATION MAIL COMPLETED FORMS TO DMV Information Services - EPN P. STATE YOUR PURPOSE FOR ENROLLMENT Be SPeciFic 2. ARE ALL OF YOUR EMPLOYEES MANDATED TO BE ENROLLED IN THE PULL NOTICE PROGRAM PURSUANT TO VEHICLE CODE SECTION 1808. 1 b Yes No NOTE Any employee who is not mandated to be enrolled in the pull notice program must have a signed waiver INF 1101 or similar on file at the employer s worksite. O. Box 944231 - MS H-265 Sacramento CA 94244-2310 PLEASE PRINT CLEARLY IN INK OR TYPE DMV USE ONLY REQUESTER CODE SECTION A ACCOUNT INFORMATION COMPANY NAME DBA ATTENTION EMAIL ADDRESS TELEPHONE NUMBER CITY ACCOUNT CONTACT PERSON EXT. ZIP CODE STREET ADDRESS PhySicAl AddreSS STATE SECTION B BILLING ADDRESS Complete only if different from above BILLING ACCOUNT CONTACT PERSON S BILLING ADDRESS SECTION C LICENSING AND BUSINESS IDENTIFICATION Instructions Complete the following on the individual participating in the direction control or management of the business. Provide federal employer identification number. NAME lASt FirSt Mi TITLE DL/ID NUMBER STATE ISSUED FEDERAL EMPLOYER IDENTIFICATION NUMBER EXPIRATION DATE 1. 3. HAS YOUR COMPANY PREVIOUSLY BEEN ISSUED A REQUESTER CODE No If yes complete the following a Company name s in which Requester Code s issued b Requester Code s previously issued SECTION E CERTIFICATION I certify or declare under penalty of perjury under the laws of the State of California that the information contained herein is true and correct to the best of my knowledge and belief* I understand that this information is provided for the lawful conduct of this business and the pursuit of its interest and that any misuse will result in both cancellation of the requester number and refusal of subsequent application for requester number. SIGNATURE OF AUTHORIZED REPRESENTATIVE SAMe PerSON AS iN SectiON c PRINT NAME OF AUTHORIZED REPRESENTATIVE X APPROVED BY DATE APPROVED DATE RECEIVED NOTE If any information submitted on this application changes you MUST submit a Notice of Change form INF 4 within 10 days. O. Box 944231 - MS H-265 Sacramento CA 94244-2310 PLEASE PRINT CLEARLY IN INK OR TYPE DMV USE ONLY REQUESTER CODE SECTION A ACCOUNT INFORMATION COMPANY NAME DBA ATTENTION EMAIL ADDRESS TELEPHONE NUMBER CITY ACCOUNT CONTACT PERSON EXT. ZIP CODE STREET ADDRESS PhySicAl AddreSS STATE SECTION B BILLING ADDRESS Complete only if different from above BILLING ACCOUNT CONTACT PERSON S BILLING ADDRESS SECTION C LICENSING AND BUSINESS IDENTIFICATION Instructions Complete the following on the individual participating in the direction control or management of the business. ZIP CODE STREET ADDRESS PhySicAl AddreSS STATE SECTION B BILLING ADDRESS Complete only if different from above BILLING ACCOUNT CONTACT PERSON S BILLING ADDRESS SECTION C LICENSING AND BUSINESS IDENTIFICATION Instructions Complete the following on the individual participating in the direction control or management of the business. Provide federal employer identification number. NAME lASt FirSt Mi TITLE DL/ID NUMBER STATE ISSUED FEDERAL EMPLOYER IDENTIFICATION NUMBER EXPIRATION DATE 1. .

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