TRUCKING INDUSTRY:
DOT D/A Disclosure and Authorization
Send to Fax# (800) 257-8069
HireRight Customer:
Company Name: Naegeli Transportation Inc.
Company Contact Name: Ellen Naegeli
Fax #: (713) 946 3000
HireRight Account Code: _____________________________


PART I - DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING


In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT - regulated drug and alcohol testing records by the DOT - regulated employer (s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above . I understand that information / documents released pursuant to this Part I is limited to the following DOT - regulated testing items , including pre - employment testing results , occurring during the previous three (3) years : (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/ or substituted tests) ; (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return - to - duty process following a rule violation.

If any company listed below furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight , if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years ; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years


List all DOT - regulated employers you have applied with and/or worked for in a safety - sensitive function during the previous three (3) years . If necessary, attach additional pages, including the date, your name, social security number and signature.
Previous DOT-Regulated Employer City State Phone Number
() -
() -
() -
() -
() -
() -

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (i ii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.

Print Applicant Name: Social Security #:
Applicant Signature: Date:
FMCSA Notification of Driver Rights

In compliance with 49 CFR Part 40 §391.23 you have certain rights regarding the safety performance history information that will be provided to prospective employers. I) You have the right to review information provided by previous employers. II) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to prospective employers. III) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2) Drivers who have previous DOT regulated employment history in the preceding three years and wish to review previous employer-provided investigative information must submit a written request to prospective employers. This may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. Prospective employers must provide this information within five business days of receiving the written request. If prospective employers have not yet received the requested information from the previous employer, then the five day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available, the prospective employers may consider you to have waived your request to review the record.

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 Naegeli Transportation Inc. (“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 Naegeli Transportation Inc. (“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.

Date: Signature
Name

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.

DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION
FOR EMPLOYMENT PURPOSES

Disclosure

Naegeli Transportation Inc. (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 Company to obtain the consumer reports described above about me.

Applicant Name:
Applicant Signature: Date:

HireRight, Inc. will be verifying the information you provided to Naegeli Transportation Inc. during the pre-employment process and researching background information at our request. Our objective is to complete this process quickly. Please make every effort to accurately provide all of the information requested on the application. A HireRight associate may contact you for additional information during the verification process. Please return the associate’s call or e-mail promptly to help ensure that your application is processed as quickly as possible.

Thank you,

The Naegeli Transportation Inc. Recruiting Team

DRIVER'S APPLICATION
FOR EMPLOYMENT
Applicant Name Date of Application
Company
Address
City State Zip


In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.



TO BE READ AND SIGNED BY APPLICANT

I understand that information I provide regarding current and/or previous 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(d) and (e). I understand I have the right to:

  • Review information provided by previous employers;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send 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.
Signature: Date


FOR COMPANY USE
PROCESS RECORD
APPLICANT HIRED REJECTED
DATE EMPLOYED POINT EMPLOYED
DEPARTMENT (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE) CLASSIFICATION
SIGNATURE OF INTERVIEWING OFFICER


TERMINATION OF EMPLOYMENT
DATE TERMINATED DEPARTMENT RELEASED FROM
DISMISSED VOLUNTARILY QUIT OTHER
TERMINATION REPORT PLACED IN FILE SUPERVISOR
Driver Application
APPLICANT TO COMPLETE
(answer all questions - please print)
Position(s) Applied for Email:
Name Social Security No

List your addresses of residency for the past 3 years.

Current Address Street City
Previous Address State Zip Code Cell Phone Phone How Long?
yr./mo.
Street City State & Zip Code How Long?
yr./mo.
Street City State & Zip Code How Long?
yr./mo.
Street City State & Zip Code How Long?
yr./mo.
Do you have the legal right to work in the United States?
Date of Birth Can you provide proof of age? (Required for Commerical Drivers)
Have you worked for this company before? Where?
Dates: From To Rate of Pay Position
Reason for leaving
Are you now employed? If not, how long since leaving last employment?
Who referred you? Rate of pay expected
Have you ever been bonded? Name of bonding company
(Answer only if a job requirement)
Can you perform, with or without reasonable accommodation, the essential functions of the job [as described in the attached job description]?         
EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7years' information on those employers for whom the applicant operated such vehicle.(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

LAST EMPLOYER              DATE
NAME FROM
MO. YR.
TO
MO. YR.
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs  WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
2ND LAST EMPLOYER              DATE
NAME FROM
MO. YR.
TO
MO. YR.
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs  WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
3RD LAST EMPLOYER              DATE
NAME FROM
MO. YR.
TO
MO. YR.
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs  WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
4TH LAST EMPLOYER              DATE
NAME FROM
MO. YR.
TO
MO. YR.
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs  WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
5TH LAST EMPLOYER              DATE
NAME FROM
MO. YR.
TO
MO. YR.
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs  WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
6TH LAST EMPLOYER              DATE
NAME FROM
MO. YR.
TO
MO. YR.
ADDRESS POSITION HELD
CITY STATE ZIP SALARY/WAGE
CONTACT PERSON PHONE NUMBER REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs  WHILE EMPLOYED?
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

 The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

DATES NATURE OF ACCIDENT
(HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES INJURIES HAZARDOUS
MATERIAL SPILL
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

LOCATION DATE CHARGE PENALTY

EXPERIENCE AND QUALIFICATIONS - DRIVER
Driver licenses or permits held in the past 3 years STATE LICENSE NO. CLASS ENDORSEMENT(S) EXPIRATION DATE
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? YES NO
B. Has any license, permit, or privilege ever been suspended or revoked? YES NO
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

DRIVING EXPERIENCE CHECK YES OR NO
CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT DATES
FROM(M/Y) TO(M/Y)
APPROX. NO. OF MILES
(TOTAL)
STRAIGHT TRUCK (VAN,TANK,FLAT,DUMP,REFER)
TRACTOR AND SEMI-TRAILER (VAN,TANK,FLAT,DUMP,REFER)
TRACTOR - TWO TRAILERS (VAN,TANK,FLAT,DUMP,REFER)
TRACTOR - THREE TRAILERS (VAN,TANK,FLAT,DUMP,REFER)
MOTORCOACH - SCHOOL BUS
OTHER
LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
EXPERIENCE AND QUALIFICATIONS - OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)


EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4
LAST SCHOOL ATTENDED (NAME) (CITY, STATE)


TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signature: Date
SAFETY PERFORMANCE HISTORY RECORDS REQUEST

RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or used him/her within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT)-regulated drug and alcohol testing.

In accordance with 49 CFR §§40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History of this individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt.

Please complete SECTION 2 below,  complete SECTIONS 3 and 4 (if applicable),


PROSPECTIVE EMPLOYEE: Complete SECTION 1 and submit to prospective employer.

PROSPECTIVE EMPLOYER: Complete SECTION 5a and send to current / previous employer. Upon receipt of completed form, complete SECTION 5b and retain.

SECTION 1:
TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
I, First, M.I., Last Social Security Number

hereby authorize: Date Of Birth
Previous Employer: Email:
Street: Phone:
City, State, Zip: Fax No.:
to release and forward the information requested by section 4 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from (date of employment application)
Prospective Employer:
Attention: Telephone:
Street:
City, State, Zip:
In compliance with §40.25(g) and §391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Prospective employer's confidential fax number:
Prospective employer's confidential email address:
Applicant's Signature Date
SECTION 2:
TO BE COMPLETED BY PREVIOUS EMPLOYER
EMPLOYMENT VERIFICATION
The applicant named above was employed or used by us.
Employed as (job title) from (m/y) to (m/y)
Did he/she drive a motor vehicle for you? If yes, what type?
Completed by
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
If there is no safety performance history to report, check here Otherwise, complete Sections 3 and 4 on SIDE 2 before returning.
-
PROSPECTIVE EMPLOYER
Employee Name: Date:
SECTION 3:
TO BE COMPLETED BY PREVIOUS EMPLOYER
ACCIDENT HISTORY

Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1, or check here

Date Location No. of Injuries No. of Fatalities Hazmat Spill
1.
2.
3.
Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:
SECTION 4:
TO BE COMPLETED BY PREVIOUS EMPLOYER
DRUG AND ALCOHOL HISTORY
If applicant was not subject to DOT testing requirements under 49 CFR Part 40 while employed by you, please check here
Applicant wassubject to DOT testing requirements from to
In answering these questions, include any required DOT drug or alcohol testing information you obtained from other employers in the 3 years prior to the application date shown on SIDE 1.
Within the past 3 years from the application date shown on SIDE 1:
1. Has this person violated any of the drug and/or alcohol prohibitions under 49 CFR Part 40 or Subpart B of Part 382, including:
  • An alcohol test with a result of 0.04 or higher alcohol concentration.
  • A controlled substances test result of positive, adulterated, or substituted.
  • A refusal to submit to a random, post-accident, reasonable-suspicion, or follow-up controlled substances or alcohol test.
  • Alcohol use while performing or within 4 hours before performing safety-sensitive functions.
  • Alcohol use after an accident, in violation of §382.303.
  • Controlled substances use while on duty, except as allowed under §382.213.
2. If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation program prescribed by Substance Abuse Professional (SAP)?
  If rehabilitation was required but you do not know if he/she began or completed such a program, check here.

3. If this person successfully completed a SAP's rehabilitation referral and remained in your employment, did he/she subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?
SECTION 5a:
TO BE COMPLETED BY PROSPECTIVE EMPLOYER
This form was (check one)
By: Date:
Subsequent attempts to contact previous employer (391.23(c)(1)):
SECTION 5b:
TO BE COMPLETED BY PROSPECTIVE EMPLOYER
Complete below when information is obtained.
Information received from:
Recorded by: Method:
Date:
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.

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, in addition to the CFPB:
a. Consumer Financial Protection Bureau 1700 G Street NW Washington, DC 20552
b. Federal Trade Commission: Consumer Response Center – FCRA 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 PO Box 1200 Minneapolis, MN 55480
c. FDIC Consumer Response Center 1100 Walnut St., 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 Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423
5. Creditors Subject to 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, SW, 8 th 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