Authorization to Drive on State Business Instructions For Non‐State Employees and Volunteers IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE EHS/RMS OFFICE AT (559) 278‐7422. Step 1. Fill out the following 4 forms (all provided in this packet): ‐Driving Authorization Process form (p.2) ‐Authorization for Release of Driver Record Information form (p.3) ‐Authorization to Use Privately Owned Vehicles on State Business ‐ if applicable (p.4) ‐Volunteer Application and Appointment form (p.5‐7) Step 2. Complete DGS Defensive Driving training course – printout required ‐Go to http://www.dgs.ca.gov/orim/Programs/DDTOnlineTraining.aspx ‐Click on the arrow in the center of the picture to begin training (see figure 1). The training consists of 11 sections and will take between 2‐2.5 hours to complete. ‐Upon completion, you must print the certificate of completion. There is no other way to confirm that you have successfully completed the training. Refer to the instructions in the Course Highlights on the web page. A legible screen shot, use of the “Print Screen” (PrtScn) button or photo of the certification page is acceptable proof of completion. If you are not sure, contact the EHS/RMS Office. Step 3. Provide copy of DMV driving record ‐ EHS will review your current DMV driving record – your record must meet University standards. This will take 24‐48 hours after we receive your forms; or ‐ To fast track obtaining your DMV record, you may use one of the two following methods: a. Order online from the California DMV for $2.00 http://dmv.ca.gov/online/onlinesvcs.htm Note: you will need to register with the website first. b. Go to local DMV; pay $5 for a copy of your driving record. ‐ Include the copy of your driving record along with your other forms. Step 4. Please submit all paperwork listed in steps 1 thru 3 (including contact info) using one of the following methods: ‐Scans/photos submitted electronically by email to ehsrmsrequest@csufresno.edu (preferred) ‐Via fax @ 278.1153 ‐Physically turn in paperwork @ EHS/RMS Office at the Plant Operations Bldg, 2nd floor ‐By campus mail at addressed to M/S PO 140 ‐The original copy of The Volunteer Application and Appointment form must be sent to the Human Resources Office at Joyal Administration 211, M/S JA 71 JH10302015
Driving Authorization Process
PLEASE PRINT - Must be legible
Last Name:
First Name:
People Soft ID:
Email:
(Student/Employee ID) Driver’s License #:
Employee Status:
State:
Registered Volunteer
Non-State Employee
Department:
Employed by:
Foundation
Dept. Mail Stop:
Auxiliary
Athletic Corp
Volunteer
Dept. Phone Extension:
Supervisor’s Name:
Please acknowledge by signature below that you will adhere to University Policy
Number G 14.1 "University Policy and Risk Management Criteria for Driving on
University (State) Business.” This policy is located at the following link:
http://www.fresnostate.edu/mapp/III/G/G-14.pdf
I acknowledge and understand that 15 passenger vans must not be rented or used for
University business.
Date
Signature
Printed Name
For Office Use Only:
New:
Renewal:
Authorization Received:
DMV Record Received:
Test Date:
Volunteer Form:
Approved:
Date sent to HR: ____________
Yes
No
Notes:_____________________________________________________________________________ JH10302015
A Public Service Agency
EMPLOYER PULL NOTICE PROGRAM
AUTHORIZATION FOR
RELEASE OF DRIVER RECORD INFORMATION
I, __________________________________________, California Driver License Number, ___________________________,
hereby authorize the California Department of Motor Vehicles (DMV) to disclose or otherwise make available, my driving
record, to my employer,_______________________________________________________________________________
COMPANY NAME
I understand that my employer may enroll me in the Employer Pull Notice (EPN) program to receive a driver record report at
least once every twelve (12) months or when any subsequent conviction, failure to appear, accident, driver’s license suspension,
revocation, or any other action is taken against my driving privilege during my employment.
I am not driving in a capacity that requires mandatory enrollment in the EPN program pursuant to California Vehicle Code
(CVC) Section 1808.1(k). I understand that enrollment in the EPN program is in an effort to promote driver safety, and that my
driver license report will be released to my employer to determine my eligibility as a licensed driver for my employment.
EXECUTED AT: CITY
DATE
COUNTY
STATE
SIGNATURE OF EMPLOYEE
X
I, ______________________________________________ , of _________________________________________________
AUTHORIZED REPRESENTATIVE
COMPANY NAME
do hereby certify under penalty of perjury under the laws in the State of California, that I am an authorized representative of
this company, that the information entered on this document is true and correct, to the best of my knowledge and that I am
requesting driver record information on the above individual to verify the information as provided by said individual. This
record is to be used by this employer in the normal course of business and as a legitimate business need to verify information
relating to a driving position not mandated pursuant to CVC Section 1808.1. The information received will not be used for any
unlawful purpose. I understand that if I have provided false information, I may be subject to prosecution for perjury (Penal
Code Section 118) and false representation (CVC Section 1808.45). These are punishable by a fine not exceeding five
thousand dollars ($5,000) or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment. I
understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant to
CVC Sections 1808.45 and 1808.46.
EXECUTED AT: CITY
DATE
COUNTY
STATE
SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE
X
To obtain a driver record on a prospective employee you may submit an INF 1119 form. To add this driver to the EPN Program
you must submit the applicable forms: INF 1100, INF 1102, INF 1103, INF 1103A form. You may obtain forms at our website
at www.dmv.ca.gov/otherservices, or by calling 916-657-6346.
THIS FORM MUST BE COMPLETED AND RETAINED AT THE EMPLOYER’S PRINCIPAL PLACE OF BUSINESS AND
MADE AVAILABLE UPON REQUEST TO DMV STAFF.
DO NOT RETURN THIS FORM TO DMV.
INF 1101 (REV. 9/2004)
VOLUNTEER APPLICATION
AND APPOINTMENT FORM
CSU FRESNO DEPARTMENT OF HUMAN RESOURCES
Please print clearly, in pen. All fields must be filled out. Completed forms must be received in the Human Resources office
1 week prior to appointment to allow for processing. Incomplete or late forms will be returned to the department.
APPLICANT INFORMATION
Campus ID #:
Full Name:
Last
First
M.I.
Address:
Street Address
City
Home Phone:
Emergency Contact:
(
Apartment/Unit #
State
)
ZIP Code
Email:
Phone: (
)
Are You Under the Age of 18? ☐YES
☐NO
If “YES” Provide Birthdate and attach Parental Release Form:
DEPARTMENT INFORMATION
Department:
Effective Start Date:
Supervisor:
End Date (NOT TO EXCEED 1 YEAR):
Campus Phone: (
)
Assignment Duties:
Will Volunteer be traveling on university business? ☐YES ☐NO
Will the Volunteer need to drive a vehicle on university business? ☐YES ☐NO
If one or more of following questions are marked “Yes” a background check will be required:
Will the volunteer be responsible for the care, safety, and security of people (including children and minors),
animals, and CSU Property? Those persons who perform work involving regular or direct contact with minor
children and those who are identified as mandated reporters or child abuse and neglect under Executive Order
1083 and California Penal Code §11165.7(a).
☐YES ☐NO
Will the volunteer have the authority to commit financial resources of the university through contracts greater than
$10,000?
☐YES ☐NO
Will the volunteer have access to, or control over cash, checks, credit cards, and/or Credit Check credit card
account information?
☐YES ☐NO
Will the volunteer be responsible or have access to or possession of building master or sub-master keys for building
access?
☐YES ☐NO
Will the volunteer have access to controlled or hazardous substances?
☐YES ☐NO
Will the volunteer have access to and responsibility for detailed personally identifiable information about students,
faculty, staff, or alumni that is protected, personal or sensitive?
☐YES ☐NO
Will the volunteer have control over campus business processes, either through functional roles or system security
access?
☐YES ☐NO
Will the volunteer have responsibilities that require him/her to possess a license, degree, credential or other
certification in order to perform the job?
☐YES ☐NO
Will the volunteer be responsible for operating commercial vehicles, machinery or equipment that could pose
environmental hazards or cause injury, illness or death?
☐YES ☐NO
This is to acknowledge that I desire to volunteer my services, performing duties similar to those listed above and that
services rendered by me will be at the direction of the above named supervisor. I will not be compensated for these
services. If applicable, I hereby authorize and request any law enforcement agency, or other persons having personal
knowledge about me, to furnish California State University (CSU) Fresno or its authorized agent with information regarding
criminal convictions or other information in their possession regarding me in connection with my volunteer role in a
sensitive assignment. I agree that a photocopy of this information can be furnished to the CSU, and that it will have the
same authority and authenticity as the original (for more information regarding the CSU background check policy please
visit our website at www.csufresno.edu/hr). Further, I understand that I serve at the pleasure of my supervisor and can
be terminated from my volunteer position at any time.
Volunteer Signature:
Date:
Dept. Head or Dean Signature:
Date:
STATE PRIVACY NOTICE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the CSU to provide the following information to individuals
who are asked to supply information about themselves:
The principle purpose for requesting and collecting the personal information on this form is to conduct background checks. CSU policy and federal
statute authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory.
The personal information will be kept confidential and used only in accordance with applicable laws.
The personal information will be given to government enforcement agencies if these agencies request such information, or as otherwise required
by law.
Information Practices Act Notice (Civil Code § 1798.17)
This information is being requested by CSU Fresno. CSU Fresno is authorized to maintain this information pursuant to Education Code §§ 89500,
89535. Submission of the information requested on this form is mandatory. Failure to provide the requested information will mean that you will be
ineligible for the position you are seeking. The principal purpose for which this information is to be used is to assist the University in evaluating
your eligibility, qualifications, and suitability for the position you are seeking. You have a right of access to records containing personal information
maintained by CSU Fresno. The name, business address and telephone number of the person at CSU Fresno who is responsible for maintaining the
requested information and will be able to inform you of the location of this information is: James Young, CSU Fresno Department of Human
Resources, 4150 N. Maple, Fresno CA 93740, 559-278-2032.
CSU FRESNO DEPARTMENT OF HUMAN RESOURCES M/S JA41
08/2015
Parental Consent Form for
Campus Volunteers
CSU FRESNO DEPARTMENT OF HUMAN RESOURCES
Please print clearly, in pen. All fields must be filled out. Completed forms must be received in the Human Resources office
1 week prior to appointment to allow for processing. Incomplete or late forms will be returned to the department.
To be completed and signed by parent/guardian of volunteer if volunteer is under 18 years of age
Event/Activity:
Date:
Volunteer Name:
Last
First
M.I.
Address:
Street Address
City
Apartment/Unit #
State
Health & Accident Insurance Contact:
Emergency Contact:
ZIP Code
Policy #:
Phone: (
)
I, _____________________________, being the parent or legal guardian of _________________________________
(the “Minor) hereby consent to and authorize the Minor to act as a volunteer for California State University (CSU)
Fresno.
I acknowledge and agree that activities performed by the minor as a volunteer will be performed strictly on a voluntary
basis, without any pay, compensation, or benefits. I agree and understand that the Minor must comply with the rules
and regulations established from time to time by the CSU and that failure to do so may result in the Minor’s immediate
removal as a volunteer.
I am aware of the nature of the activities to be performed by the Minor as a volunteer. I agree that all volunteer
activities are to be performed by the Minor at the Minor’s risk and I assume full responsibility therefore.
On behalf of myself, the Minor, and our respective heirs and personal representatives, I agree to indemnify and hold the
State of California, the Trustees of the California State University, CSU Fresno and all of its officers, employees,
representatives and volunteers free and harmless from and against all claims, damages, losses and expenses, including
attorney fees, that my minor child may sustain while participating in the volunteer activity. I hereby release and
discharge the CSU and the Trustees of CSU Fresno and all of its officers, employe es, representatives and volunteers from
any and all claims, demands, causes of action of any nature or cause, for any such injury or damage incurred or suffered
by the Minor.
Parent/Legal Guardian Signature
I have carefully read this agreement, waiver and release and fully understand its contents. I am aware that this is a release of
liability and a contract between CSU Fresno and myself and I sign it of my own free will.
Print Full Name:______________________________________________
Signature:
_______________________________________________
Date:________________________________