Electronic Pull Notice Program

"THIS AGREEMENT is made and entered into this ---- day of 20 , ---- between the NATIONAL SAFETY COMPLIANCE, INC., acting by and through the State of California, DEPARTMENT OF MOTOR VEHICLES, herein called SELLER, and , herein called BUYER. BUYER desires to purchase information from SELLER'S record under the terms and conditions and at the rates set forth in the "NSC Employer Pull Notice Program, Information For Enrollment," attached hereto and hereby incorporated and made a part of this contract. SELLER will furnish information in accordance with the terms specified below:

1. SELLER will furnish said information as soon as possible after receipt of request, and will furnish a subsequent report each time a record is updated under the following conditions while the BUYER'S notification request remains valid and uncanceled: abstracts of conviction, failure to appear notices, failure to pay notices, accidents, suspensions, revocations or any other actions taken against the driving privilege or certificate.

2. BUYER will not use any information or portions of information acquired under the provisions of this contract for any purpose other than administering company policies in regard to the driving record requirements of employees. BUYER will not sell, assign or otherwise transfer any of the information or portions of information acquired under the provisions of this contract. For breach of this condition, or if the buyer fails to pay money owed the seller within 45 days of billing, the SELLER may elect to cancel this contract immediately upon notice to the BUYER.

3. All sensitive data, documentation, or other information, which is designated confidential by SELLER and is inadvertently made available to BUYER will be protected by BUYER from unauthorized use and disclosure.

4. BUYER agrees to defend, indemnify and hold harmless SELLER and its officers, agents and employees from any and all claims, actions, damages and losses which may be brought or alleged against SELLER, its officers, agents or employees by reason of the negligent, intentional, improper or unauthorized use or dissemination by BUYER, or its officers, agents or employees of accurate information furnished to BUYER by SELLER under this Agreement.

5. No alteration or variation of the terms of this Agreement shall be valid unless made in writing and signed by the parties hereto, and no oral understanding or agreement not incorporated herein shall be binding on any of the parties hereto.

6. This Agreement is not assignable by BUYER either in whole or in part.

7. BUYER and its agents or employees shall act in an independent capacity and not as officers, employees or agents of SELLER.

8. This Agreement is subject to any restrictions, limitations or conditions enacted by the Legislature which may affect the provisions or terms of this Agreement in any manner.

9. Except for the election of SELLER to cease furnishing information or to cancel this contract upon notice as above provided, this contract shall continue until canceled by either party upon at least thirty (30) days written notice to the other.

I agree.
I disagree

Company Information:
Need Requester Code ? Click Here
* Requester Code:
* Primary E-mail Address: (This e-mail address will be used for logging into the system and receiving all system notifications.)
* Password:
* Confirm password:
* Security Question:
* Security Answer:
* Company name:
DBA:
* Attention:
* Email Address:
* Telephone Number:
* Mailing Address:
* City:
* State:
* Zip Code:

BILLING OPTION
* Billing type:	Auto Pay Monthly Invoice
By continuing with the MONTHLY INVOICE billing option, you will receive an invoice monthly for all transactions associated with your account. The terms of the invoice for EPN services in NET 15. Invoices will be sent directly to your primary email address listed in your profile. Please note that this option will require approval by National Safety Compliance, Inc. (please allow up to one business day).
By continuing with the AUTO PAY billing option, the credit card information you provide below will be charged automatically at the end of each months billing cycle. Invoice details will be sent to your primary email address in your profile after billing is complete.
CREDIT CARD BILLING: same as company information
* Card Holder Name:
* Card Holder Phone Number:
* Card Holder Address:
* Card Holder City:
* Card Holder State:
* Card Holder Zip Code:
* Credit Card Number:
* Expiration Date:

ACCOUNT CONTACT INFORMATION: SAME AS COMPANY INFORMATION
* Account Contact Person:
* Telephone Number:
* Street Address (Physical Address):
* City:
* State:
* Zip Code:

BILLING INFORMATION: same as company information
* Billing Contact Person:
* Telephone Number:
* Attention:
* Billing Address:
* City:
* State:
* Zip Code:
LICENSING & BUSINESS IDENTIFICATION
* Name:
* Title:
* Driver’s License Number:
* Expiration date:
* State Issued:
* Email Address:
* Federal EIN: (please include hyphens)

ACCOUNT USE & HISTORY
Are your employees mandated to be enrolled in the Pull Notice Program Pursuant to Vehicle Code Section 1808.1(b)?	No Yes
State your purpose for enrollment:
(Note any employee who is not mandated to be enrolled in the pull notice program must have a signed waiver (DMV Form INF 1101 or similar) on file at the employer’s worksite.)
Has your company previously been issued a requester code?	No Yes
* Company Name(s) in which Requester Code(s) issued:
* Requester Code(s) previously issued:
CERTIFICATION:
You must digitally agree and certify below to use this system: I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. The driver(s) I will enter into this system are (1) mandated for enrollment under California Vehicle Code $1808.1 OR (2) have signed an "Authorization for Release of Driver Record Information" form (INF 1101) or internal documents with similar language AND are currently in an employer/employee relationship AND frequently drive during the course of their employment.
Executed City:
Executed County:
Executed State:

Date:
Printed Name of Authorized representative
Signature of authorized representative
AGREEMENT:
Terms & Conditions:	Terms & Conditions: I agree I disagree

Electronic Pull Notice Program

CALIFORNIA DMV – EMPLOYER PULL NOTICE PROGRAM ENROLLMENT

Company Information:

BILLING OPTION

CREDIT CARD BILLING: same as company information

ACCOUNT CONTACT INFORMATION: SAME AS COMPANY INFORMATION

BILLING INFORMATION: same as company information

LICENSING & BUSINESS IDENTIFICATION

ACCOUNT USE & HISTORY

CERTIFICATION:

AGREEMENT:

CREDIT CARD BILLING:
same as company information

ACCOUNT CONTACT INFORMATION:
SAME AS COMPANY INFORMATION

BILLING INFORMATION:
same as company information