DRIVER APPLICATION (With PSP and MVR Authorizations)

EMPLOYMENT HISTORY
As required by FMCSA regulations (49 CFR § 391.21(b)(11)), applicants must provide a complete list of all employers for the past 10 years. Include employer names, dates of employment, and reasons for leaving.

Note: When listing previous employers, begin with your most recent employer first.

I understand that leaving out any employer from the past ten (10) years (2015–2025) is considered falsification of my application and may disqualify me from employment with Davis Cartage Co.*
Place Your Initials in the Box Above

DRIVING RECORD
CURRENT DRIVERS LICENSE NUMBER*
CURRENT DRIVERS LICENSE EXPIRATION DATE*

ACCIDENT RECORD FOR THE PAST 5 YEARS

Rows	DATES	NATURE OF ACCIDENT	#INJURED	#FATALITIES
ACCIDENT 1
ACCIDENT 2
ACCIDENT 3
ACCIDENT 4
ACCIDENT 5

HAVE YOU BEEN IN AN ACCIDENT IN THE LAST 5 YEARS?*

YESNO
TRAFFIC CONVICTIONS IN PAST 5 YEARS? (DO NOT INCLUDE PARKING)

TRAFFIC CONVICTIONS IN THE PAST 5 YEARS (DO NOT INCLUDE PARKING)

Rows	LOCATION	DATE	TYPE OF VIOLATION	PENALTY - POINTS ON LICENSE?
ACCIDENT 1
ACCIDENT 2
ACCIDENT 3
ACCIDENT 4
ACCIDENT 5

DRIVING HISTORY

PAST DRIVERS LICENSE(S) (Include any past state licenses held in the last 10 years)

Rows	STATE	TYPE (commercial/non-commercial)	DRIVER LICENSE NUMBER (please enter the correct license number carefully)	EXPIRATION DATE
LICENSE 1
LICENSE 2
LICENSE 3
LICENSE 4

Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

YESNO
PLEASE EXPLAIN
Has any license, permit or privilege even been suspended or revoked?*

YESNO
PLEASE EXPLAIN
Have you ever held a driver's license in any state other than the license you are currently holding?*

YESNO
PLEASE EXPLAIN
Have you ever pled guilty, accepted diversion or been convicted of any criminal offense other than a minor traffic violation? If so, please explain.*

YESNO
PLEASE EXPLAIN

DRIVING EXPERIENCE

Must have at least 2 years CDL driving experience, excluding school & military. Class of equipment could include van, tank, flat, etc.
PLEASE DESCRIBE BELOW WHAT EXPERIENCE YOU HAVE, BY LISTING THE CLASS AND TYPE OF EQUIPMENT YOU HAVE DRIVEN, ALONG WITH THE DATES AND APPROXIMATE MILES DRIVEN.
Example: I have driven a Tractor-Dry Van Trailer for 7 years and logged about 700,000 miles. I have also driven a Tractor-Flat Bed Trailer for 2 years and logged about 200,000 miles.
PLEASE LIST STATES OPERATED IN FOR THE LAST 5 YEARS
PLEASE LIST ANY SAFE DRIVING AWARDS YOU HAVE RECEIVED

Consent & Signature
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

Review information provided by current/previous employers;

Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and

Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

If hired, I agree I will serve at the will of the Company, and I agree that I shall be bound by the rules, policies, regulations and terms and conditions of employment of the Company as they are from time to time changed with or without notice to me. I AGREE THAT EITHER PARTY MAY TERMINATE THE EMPLOYMENT RELATIONSHIP, WITH OR WITHOUT CAUSE, AT ANY TIME. I agree that these arrangements may only be altered in writing directed to me personally by the President of the Company. I further agree that my employment is conditional upon satisfactorily completion of documentation as required by the Immigration Reform and Control Act of 1986 and until such time as the results of my employment physical (if such physical is required) are known.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
YOUR SOCIAL SECURITY NUMBER*
Print Name*
Applicant’s Signature*
Date*

MonthDayYear
Date
Email Address*
example@example.com

PSP - AUTHORIZATION
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Davis Cartage Co (“Prospective Employer”), Prospective

Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Davis Cartage Co. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49
C.F.R. 383.5.

LAST UPDATED 2/11/2016
Signature*
Date*

MonthDayYear
Date
FIRST AND LAST NAME *
CLICK BELOW TO VIEW THE FCRA SUMMARY OF RIGHTS

OpenClose
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

·         You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

·         You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

·         a person has taken adverse action against you because of information in your credit report;

·         you are the victim of identity theft and place a fraud alert in your file;

·         your file contains inaccurate information as a result of fraud;

·         you are on public assistance;

·         you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

·         You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

·         You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

·         Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

·         Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

·         Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

·         You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

·         You many limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

·         You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

·         Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS:
CONTACT:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates

b. Such affiliates that are not banks, savings associations, or credit unions also should list,
a. Consumer Financial Protection Bureau 1700 G Street, N.W.

Washington, DC 20552

b. Federal Trade Commission: Consumer Response Center – FCRA

in addition to the CFPB:
Washington, DC 20580

(877) 382-4357
2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the Currency Customer Assistance Group

1301 McKinney Street, Suite 3450

Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center

P.O. Box. 1200

Minneapolis, MN 55480

c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106

d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO)

1775 Duke Street

Alexandria, VA 22314
3. Air carriers
Asst. General Counsel for Aviation Enforcement & Proceedings

Aviation Consumer Protection Division Department of Transportation

1200 New Jersey Avenue, S.E. Washington, DC 20590
4. Creditors Subject to the Surface Transportation Board
Office of Proceedings, Surface Transportation Board

Department of Transportation 395 E Street, S.W. Washington, DC 20423
5. Creditors Subject to the Packers and

Stockyards Act, 1921
Nearest Packers and Stockyards

Administration area supervisor
6. Small Business Investment Companies
Associate Deputy Administrator for Capital Access

United States Small Business Administration

409 Third Street, S.W., 8th Floor Washington, DC 20416
7. Brokers and Dealers
Securities and Exchange Commission 100 F Street, N.E.

Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit

Banks, and Production Credit Associations
Farm Credit Administration 1501 Farm Credit Drive

McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above
FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA

Washington, DC 20580

(877) 382-4357

MVR - AUTHORIZATION
DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Disclosure

Davis Cartage Company (the “Company”) may request from a consumer reporting agency and for employment-related purposes, a “consumer report(s)” (commonly known as “background reports”) containing background information about you in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable).

HireRight, LLC (“HireRight”) will prepare or assemble the background reports for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761, www.hireright.com.

The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.

Authorization

I hereby authorize Davis Cartage Company to obtain the consumer reports described above about me.
Applicant Name*
Signature*
Date*

MonthDayYear
Date

MVR - AUTHORIZATION CONTINUED
Acknowledgments & Authorization

I acknowledge that I have received and carefully read and understand the separate “Disclosure and Authorization Regarding Background Investigation for Employment Purposes”; and the separate “Summary of Rights under the Fair Credit Reporting Act” that have been provided to me by the Company. I also acknowledge receipt of and that I have carefully read and understand (as applicable), the separate California Disclosure and Summary of Rights under California Civil Code Section 1786.22; the separate New York Article 23-A; and the separate San Francisco Fair Chance Ordinance Official Notice that have been provided to me.

By my signature below, I authorize the preparation of background reports about me, including background reports that are “investigative consumer reports” by HireRight, and to the furnishing of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment or engagement for services (including independent contractor or volunteer assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain from HireRight (or from a consumer reporting agency other than HireRight) additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period.

I understand that if the Company obtains a credit report about me, then it will only do so where such information is substantially related to the duties and responsibilities of the position in which I am engaged or for which I am being evaluated.

I understand that information contained in my employment (or contractor or volunteer) application, or otherwise disclosed by me before or during my employment (or contract or volunteer assignment), if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.

I understand that the information included in the background reports may be obtained from private and public record sources, including without limitation and as appropriate: government agencies and courthouses; educational institutions; and employers. Accordingly, I hereby authorize all of the following, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local government agencies and courts; educational institutions (public or private); testing agencies; information service bureaus; credit bureaus and other consumer reporting agencies; other public and private record/data repositories; motor vehicle records agencies; my employers; the military; and all other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my: employment and earnings history; education, credit, motor vehicle and accident history; drug/alcohol testing results and history; criminal history; litigation history; military service; professional licenses, credentials and certifications; social security number verification; address and alias history; and other information.

By my signature below, I also promise that the personal information I provide with this form or otherwise in connection with my background investigation is true, accurate and complete, and I understand that dishonesty or material omission may disqualify me from consideration for employment. I agree that a copy of this document in faxed, photocopied or electronic (including electronically signed) form will be valid like the signed original. I further acknowledge that I have received additional state law notices that I have reviewed and read.
Applicant *

First NameLast Name
Signature*
Date*

MonthDayYear
Date
CLICK BELOW TO VIEW THE FCRA SUMMARY OF RIGHTS

OpenClose
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

·         You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

·         You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

·         a person has taken adverse action against you because of information in your credit report;

·         you are the victim of identity theft and place a fraud alert in your file;

·         your file contains inaccurate information as a result of fraud;

·         you are on public assistance;

·         you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

·         You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

·         You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

·         Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

·         Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

·         Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

·         You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

·         You many limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

·         You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

·         Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS:
CONTACT:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates

b. Such affiliates that are not banks, savings associations, or credit unions also should list,
a. Consumer Financial Protection Bureau 1700 G Street, N.W.

Washington, DC 20552

b. Federal Trade Commission: Consumer Response Center – FCRA

in addition to the CFPB:
Washington, DC 20580

(877) 382-4357
2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the Currency Customer Assistance Group

1301 McKinney Street, Suite 3450

Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center

P.O. Box. 1200

Minneapolis, MN 55480

c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106

d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO)

1775 Duke Street

Alexandria, VA 22314
3. Air carriers
Asst. General Counsel for Aviation Enforcement & Proceedings

Aviation Consumer Protection Division Department of Transportation

1200 New Jersey Avenue, S.E. Washington, DC 20590
4. Creditors Subject to the Surface Transportation Board
Office of Proceedings, Surface Transportation Board

Department of Transportation 395 E Street, S.W. Washington, DC 20423
5. Creditors Subject to the Packers and

Stockyards Act, 1921
Nearest Packers and Stockyards

Administration area supervisor
6. Small Business Investment Companies
Associate Deputy Administrator for Capital Access

United States Small Business Administration

409 Third Street, S.W., 8th Floor Washington, DC 20416
7. Brokers and Dealers
Securities and Exchange Commission 100 F Street, N.E.

Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit

Banks, and Production Credit Associations
Farm Credit Administration 1501 Farm Credit Drive

McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed Above
FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA

Washington, DC 20580

(877) 382-4357
Should be Empty:

DRIVER’S

EMPLOYMENT HISTORY

DRIVING RECORD

DRIVING HISTORY

DRIVING EXPERIENCE

Consent & Signature