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A Pebt Sem~ <br /> <br /> APPLICATION FOR EMPLOYER PULL NOTICE ACCOUNT <br /> <br /> PART A (PLEASE PRINT') <br /> <br /> PART B (ANSWER THE FOLLOWING QUESTIONS) <br /> <br /> 1. Are you requested to participate in the Employer Pull Notice Program? <br /> E:] YES r"] NO If you answer no, state your purpose for enrollment. <br /> <br />2. If you am required to participate, please indicate the type of drivers you employ. Check more than one box if needed. <br /> E] Ddver with Class A or B driver license. <br /> E:] Driver of a limousine. <br /> E:] Ddver required to have a Tour Bus Certfficate. <br /> r"l Ddver carrying material which requires warning placems. <br /> E::] Other (Describe briefly if not listed above.) <br /> <br />PART C (READ AND SIGN) <br /> <br />I certify under penalty of perjury that the information contained heroin is true and correct to the best of my knowledge <br />and belief. I understand that this information is provided for the laWful conduct of this business and the pursuit of <br />its interest and that any misuse will result in beth cancellation of the requester number and refusal of sul3~Nl~ <br />application for requester number. <br />SIGNATURE OF AUTHORIZED REPRESENTATIVE ~ <br /> FOR DMV USE ONLY wm <br /> PRINT NAJME OF AUTHORIZED REPRESENTATIVE -TITLE APPROVED BY ~) <br /> <br /> m <br /> MAIL COMPLETED ~ 1'O: lATE ~ <br /> <br /> DMV Information Services ~- <br /> P. O. Box 944231 ~UTOMATEO REK~T g <br /> SacramentO, CA 94244-2310 O <br /> <br /> INF 1104 (NEW 12/95) <br /> <br /> <br />