Employee Employer Pull Notice

EMPLOYEE EMPLOYER PULL NOTICE ENROLLMENT & CONSENT

Employer Name:

Program Summary

This form documents enrollment of the named employee in the Employer Pull Notice program and provides the employer with ongoing access to the employee's driving record as permitted by applicable motor vehicle record laws. Enrollment covers review of motor vehicle reports (MVR) for employment purposes and notification to the employer of qualifying events such as convictions, license suspensions, revocations, and other changes to the driving record.

Employer Contact

Employee Personal Information

Date of Birth:

Driver Licensing & Position Information

Driver's License Number:    State of Issue:

License Class/Endorsements:    Expiration Date:

Employment Start Date:

Employment History (Most Recent)

Previous Employment (Prior)

Education

Professional References

Acknowledgments, Consent & Certifications

I certify that the information provided on this form is true and complete. I authorize the Employer and its designated agents and service providers to obtain my motor vehicle record and other driving-related information now and at any time during my employment tenure as permitted by law. This authorization includes enrollment in the Employer Pull Notice program and receipt of automatic notifications of reportable driving-record events.

I further authorize previous employers, law enforcement agencies, and licensing authorities to release driving-history information to the Employer or its agents for the purposes of assessing and maintaining driving qualifications. I voluntarily release and hold harmless the Employer, its agents, and any information providers from liability for providing or using such information in good faith for employment-related decisions.

I understand that enrollment in Pull Notice is a condition of my employment for positions requiring driving duties, and that motor-vehicle related convictions, suspensions, or other disqualifying events may affect my eligibility to perform driving assignments and may result in discipline up to and including termination in accordance with Employer policy.

By checking the boxes below I expressly consent to the Employer obtaining initial and periodic motor vehicle reports and receiving notice of any subsequent reportable changes to my driving record.

Employee obligation: I agree to notify the Employer within days of any citation, conviction, license suspension, revocation, or disqualification that affects my ability to drive on behalf of the Employer.

At-Will Employment & Equal Opportunity

Nothing in this enrollment form alters the at-will nature of employment unless expressly provided in a separate written agreement. The Employer is an equal opportunity employer and does not discriminate in hiring or employment on the basis of protected characteristics. Enrollment in Pull Notice is applied uniformly to positions that require driving as a job function.

Background Check Authorization

I authorize the Employer to conduct background checks, including but not limited to criminal history and driving record checks, as necessary to evaluate my suitability for employment and continued qualification for driving duties. I understand a conviction will not automatically disqualify me but will be considered in light of the nature and relevance of the offense.

I certify under penalty of perjury that the foregoing is true and correct. I understand falsification or omission of information may be grounds for refusal to hire or for termination. I authorize the Employer to verify any information provided and to contact prior employers and references for the purpose of evaluating my qualifications and driving history.

Acknowledgment of Receipt

Employee acknowledges receipt of this enrollment and consent form and understands the Employer's right to receive driving-record notifications. Employee retains the right to withdraw consent in writing, subject to any business necessity for continued monitoring where required by the position.

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