FAX to or to Drayage. Address West Columbia Street, Schuylkill Haven, Pennsylvania 17972

Transcription

1 APPLICATION FAX t r t SAFETY@ACE-SAVANNAH.COM šmv01`œ Cmpany Carrier Evans West Agent Cde CTI Drayage Madaris Catfish X Address West Clumbia Street, Schuylkill Haven, Pennsylvania A N S W E R A L L Q U E S T I O N S P L E A S E P R I N T C L E A R L Y Name FIRST MIDDLE LAST SUFFIX (IF ANY) ACE Scial Security # Date f Birth Male Female Hme Address City State Zip Address Are yu a U.S. Citizen? Yes N Hme Phne Cell Phne Shirt Size Fr Cmpany-Prvided Safety Gear Cell Phne Carrier AT&T, Cricket, T-Mbile, Sprint, U.S. Cellular, Verizn, etc. (Needed fr text messaging purpses.) CURRENT DRIVER LICENSE State License N. Class/Type Expiratin Date PREVIOUS DRIVER LICENSES FOR THE PAST THREE (3) YEARS (Attach a separate sheet if mre space is needed) State License N. Class/Type Expiratin Date State License N. Class/Type Expiratin Date State License N. Class/Type Expiratin Date DRIVING EXPERIENCE Class A (semi-tractrs): Number f years and mnths perated Types f Trailers Transprted/Operated Dry Van Reefer Flatbed Duble/Triples Tanker Pneumatic Dump Trailer Hpper Intermdal Aut Hauler Specialized Ht Sht Other (please list) Have yu ever been leased t this cmpany and/r t The Evans Netwrk f Cmpanies in the past? If yes, please explain Are yu currently wrking fr r leased t any ther emplyers/carriers, either full time r part-time? Yes N Lg ID, if knwn Yes N If n, please explain (and hw lng?) Rev. 08/15/2016 Applicatin Page 1 f 5

2 Applicant Name PAST EMPLOYMENT OR LEASE RECORD FOR THE PAST TEN (10) YEARS List ALL past emplyment fr the last 10 years including DOT regulated, leased cntracts, and nn DOT regulated. Frm T Reasn fr Leaving CDL Class A?... Yes N Was yur jb subject t DOT alchl and drug testing as required by 49 CFR Part 40?... Yes N Were yu subject t FMCSRs while emplyed/leased by this cmpany?... Yes N Frm T Reasn fr Leaving CDL Class A?... Yes N Was yur jb subject t DOT alchl and drug testing as required by 49 CFR Part 40?... Yes N Were yu subject t FMCSRs while emplyed/leased by this cmpany?... Yes N Frm T Reasn fr Leaving CDL Class A?... Yes N Was yur jb subject t DOT alchl and drug testing as required by 49 CFR Part 40?... Yes N Were yu subject t FMCSRs while emplyed/leased by this cmpany?... Yes N Frm T Reasn fr Leaving CDL Class A?... Yes N Was yur jb subject t DOT alchl and drug testing as required by 49 CFR Part 40?... Yes N Were yu subject t FMCSRs while emplyed/leased by this cmpany?... Yes N Frm T Reasn fr Leaving CDL Class A?... Yes N Was yur jb subject t DOT alchl and drug testing as required by 49 CFR Part 40?... Yes N Were yu subject t FMCSRs while emplyed/leased by this cmpany?... Yes N Use multiple cpies f this page if mre space is needed t list all past emplyers/leased cmpanies fr the past ten (10) years. šmv02dœ Rev. 8/15/2016 Applicatin Page 2 f 5

3 Applicant Name šmv03hœ VIOLATIONS OF MOTOR VEHICLE LAWS r ORDINANCES FOR PAST THREE (3) YEARS Please d nt list parking vilatins. (Attach a separate sheet if mre space is needed.) If n vilatins, please write NONE. DATE OF CONVICTION OFFENSE LOCATION TYPE OF MOTOR VEHICLE OPERATED MOTOR VEHICLE ACCIDENTS FOR PAST FIVE (5) YEARS (Attach a separate sheet if mre space is needed) If n accidents, write NONE. DATE DESCRIPTION OF THE ACCIDENT TOWED? YES/NO # OF FATALITIES # OF INJURIES Have yu ever had yur license, permit, r driving privileges suspended and/r revked?... Yes N If yes, please explain Have yu ever been cnvicted f a felny?... Yes N If yes, please explain Have yu ever been cnvicted f driving while intxicated r under the influence f drugs r alchl?... Yes N If yes, please explain Have yu failed any DOT required alchl and/r drug testing within the past three (3) years?... Yes N If yes, please explain IN CASE OF EMERGENCY, PLEASE CONTACT: At least ne (1) emergency cntact is required. NAME RELATIONSHIP AREA CODE and PHONE NUMBER NAME RELATIONSHIP AREA CODE and PHONE NUMBER Rev. 8/15/2016 Applicatin Page 3 f 5

4 Applicant Name šmv04lœ FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accrdance with the prvisin f Sectin 604(b)(2)(A) f the Fair Credit Reprting Act, Public Law , as amended by the Cnsumer Credit Reprting Act f 1996 (Title II, Subtitle D, Chapter I, f Public Law ), yu are being infrmed that reprts verifying yur previus emplyment r lease, previus drug and alchl test results, and yur driving recrd may be btained n yu fr emplyment r lease purpses. These reprts are required by Sectins , , and f the Federal Mtr Carrier Safety Regulatins. DRIVER NOTIFICATION This ntice serves t fulfill the requirements f 49 CFR Part (i). Each mtr carrier must ntify each driver, wh is regulated by the Department f Transprtatin, f their rights regarding investigative infrmatin that will be prvided t a prspective emplyer r leasing cmpany. Drivers have: The right t review infrmatin prvided by previus emplyers; The right t have errrs in the infrmatin crrected by the previus emplyer and fr that previus emplyer t re-send the crrected infrmatin t the prspective emplyer; The right t have a rebuttal statement attached t the alleged errneus infrmatin, if the previus emplyer and the driver cannt agree n the accuracy f the infrmatin. PAST PRE-EMPLOYMENT DRUG & ALCOHOL TESTING QUESTION In accrdance with 49 CFR Part 40.25(j) The Evans Netwrk f Cmpanies is required t ask applicants: 1. Have yu ever tested psitive, r refused t test, n any pre-emplyment drug r alchl test administered by an emplyer/carrier t which the emplyee applied fr, but did nt btain, safety-sensitive transprtatin wrk cvered by DOT agency drug and alchl testing rules during the past three (3) years? CHECK ONE: Yes N 2. If yu answered yes, can yu prvide/btain prf that yu ve successfully cmpleted the DOT return-t-duty requirements? CHECK ONE: Yes N TO BE READ AND SIGNED BY THE APPLICANT This certifies that this applicatin and any additinal past emplyer/carrier recrds and/r any ther attachments have been cmpleted by me, and that all entries n it and infrmatin in it are true and cmplete t the best f my knwledge. I understand that if leased r hired, any misstatement r missin f fact n this applicatin shall be cnsidered cause fr cancellatin f my lease r emplyment. I authrize investigatin f all statements cntained in this applicatin as may be necessary in arriving at a decisin. APPLICANT SIGNATURE DATE OF APPLICATION APPLICANT S PRINTED NAME Rev. 8/15/2016 Applicatin Page 4 f 5

5 Imprtant Disclsure Regarding Backgrund Reprts frm the PSP Online Service šmv05pœ Cmpany Carrier Agent Cde ACE Evans West CTI Drayage Madaris Catfish Address West Clumbia Street, Schuylkill Haven, Pennsylvania In cnnectin with yur applicatin fr emplyment with the abve named-cmpany ( Prspective Emplyer ), Prspective Emplyer, its emplyees, agents r cntractrs may btain ne r mre reprts regarding yur driving, and safety inspectin histry frm the Federal Mtr Carrier Safety Administratin (FMCSA). When the applicatin fr emplyment is submitted in persn, if the Prspective Emplyer uses any infrmatin it btains frm FMCSA in a decisin t nt hire yu r t make any ther adverse emplyment decisin regarding yu, the Prspective Emplyer will prvide yu with a cpy f the reprt upn which its decisin was based and a written summary f yur rights under the Fair Credit Reprting Act befre taking any final adverse actin. If any final adverse actin is taken against yu based upn yur driving histry r safety reprt, the Prspective Emplyer will ntify yu that the actin has been taken and that the actin was based in part r in whle n this reprt. When the applicatin fr emplyment is submitted by mail, telephne, cmputer, r ther similar means, if the Prspective Emplyer uses any infrmatin it btains frm FMCSA in a decisin t nt hire yu r t make any ther adverse emplyment decisin regarding yu, the Prspective Emplyer must prvide yu within three business days f taking adverse actin ral, written r electrnic ntificatin: that adverse actin has been taken based in whle r in part n infrmatin btained frm FMCSA; the name, address, and the tll free telephne number f FMCSA; that the FMCSA did nt make the decisin t take the adverse actin and is unable t prvide yu the specific reasns why the adverse actin was taken; and that yu may, upn prviding prper identificatin, request a free cpy f the reprt and may dispute with the FMCSA the accuracy r cmpleteness f any infrmatin r reprt. If yu request a cpy f a driver recrd frm the Prspective Emplyer wh prcured the reprt, then, within 3 business days f receiving yur request, tgether with prper identificatin, the Prspective Emplyer must send r prvide t yu a cpy f yur reprt and a summary f yur rights under the Fair Credit Reprting Act. Neither the Prspective Emplyer nr the FMCSA cntractr supplying the crash and safety infrmatin has the capability t crrect any safety data that appears t be incrrect. Yu may challenge the accuracy f the data by submitting a request t If yu challenge crash r inspectin infrmatin reprted by a State, FMCSA cannt change r crrect this data. Yur request will be frwarded by the DataQs system t the apprpriate State fr adjudicatin. Any crash r inspectin in which yu were invlved will display n yur PSP reprt. Since the PSP reprt des nt reprt, r assign, r imply fault, it will include all Cmmercial Mtr Vehicle (CMV) crashes where yu were a driver r c-driver and where thse crashes were reprted t FMCSA, regardless f fault. Similarly, all inspectins, with r withut vilatins, appear n the PSP reprt. State citatins assciated with Federal Mtr Carrier Safety Regulatins (FMCSR) vilatins that have been adjudicated by a curt f law will als appear, and remain, n a PSP reprt. The Prspective Emplyer cannt btain backgrund reprts frm FMCSA withut yur authrizatin. AUTHORIZATION If yu agree that the Prspective Emplyer may btain such backgrund reprts, please read the fllwing and sign belw: I authrize the abve-named Cmpany ( Prspective Emplyer ) t access the FMCSA Pre-Emplyment Screening Prgram (PSP) system t seek infrmatin regarding my cmmercial driving safety recrd and infrmatin regarding my safety inspectin histry. I understand that I am authrizing the release f safety perfrmance infrmatin including crash data frm the previus five (5) years and inspectin histry frm the previus three (3) years. I understand and acknwledge that this release f infrmatin may assist the Prspective Emplyer t make a determinatin regarding my suitability as an emplyee. I further understand that neither the Prspective Emplyer nr the FMCSA cntractr supplying the crash and safety infrmatin has the capability t crrect any safety data that appears t be incrrect. I understand I may challenge the accuracy f the data by submitting a request t If I challenge crash r inspectin infrmatin reprted by a State, FMCSA cannt change r crrect this data. I understand my request will be frwarded by the DataQs system t the apprpriate State fr adjudicatin. I understand that any crash r inspectin in which I was invlved will display n my PSP reprt. Since the PSP reprt des nt reprt, r assign, r imply fault, I acknwledge it will include all CMV crashes where I was a driver r c-driver and where thse crashes were reprted t FMCSA, regardless f fault. Similarly, I understand all inspectins, with r withut vilatins, will appear 2 n my PSP reprt, and State citatins assciated with FMCSR vilatins that have been adjudicated by a curt f law will als appear, and remain, n my PSP reprt. I have read the abve Disclsure Regarding Backgrund Reprts prvided t me by Prspective Emplyer and I understand that if I sign this Disclsure and Authrizatin, Prspective Emplyer may btain a reprt f my crash and inspectin histry. I hereby authrize Prspective Emplyer and its emplyees, authrized agents, and/r affiliates t btain the infrmatin authrized abve. Date: Signature Name (Please Print) Rev. 8/15/2016 (PSP Frm Page 1 f 1) Applicatin Page 5 f 5

6 REFERENCE CHECK PAST EMPLOYMENT/LEASE SAFETY HISTORY REQUEST FROM: The Evans Netwrk f Cmpanies, W Clumbia St, Schuylkill Haven PA 17972, , x1 šre01cœ The persn named herein has applied t The Evans Netwrk f Cmpanies t drive in a safety-sensitive psitin. Applicant Printed Name Scial Security # I, the listed applicant, hereby authrize the fllwing cmpany(s) t release all recrds f emplyment/lease, including assessments f my jb perfrmance, ability, fitness and drug testing results t The Evans Netwrk f Cmpanies. I hereby release the belw listed cmpany(s), and its emplyees, fficers, directrs, and agents frm any and all liability f any type as a result f prviding the fllwing infrmatin t the abve-mentined cmpany. The applicant s signature n this frm releases all liability f yu and yur cmpany. Infrmatin is being requested in accrdance with 49 CFR Parts 40, 382 and 391. DATE APPLICANT SIGNATURE Past Emplyer/Carrier: Address TO BE COMPLETED BY PAST EMPLOYER/CARRIER Phne Fax Dates f emplyment: Frm / / T / / Full Time Part-Time Psitin(s) Held: Lcal Reginal Over-the-Rad Did this driver perate cmmercial mtr vehicles greater than 26,000 lbs. GVWR? Yes N Type f equipment perated: Dry Van Flatbed Reefer Other (please list): Reasn fr leaving: Vluntary Lay-Off Retired Terminated (please explain) Eligible fr rehire? Yes N Upn Review N, Cmpany Plicy: Mtr Vehicle Accident/Equipment Damage/Incident Inquiry. If n accidents please check here: Nne Accident Date City, State Did the Accident Invlve? Brief Descriptin / / / / / / / / Tw Injury Fatality HM Release Tw Injury Fatality HM Release Tw Injury Fatality HM Release Tw Injury Fatality HM Release Alchl & Cntrlled Substance Testing Inquiry Has this driver ever had a breath alchl test within the past 3 years a result f 0.04 r higher alchl cncentratin?.. Yes N Has this driver ever had a psitive drug test in the past 3 years?... Yes N Has this driver refused a cntrlled substance test and/r alchl test within the past 3 years?... Yes N Has this driver vilated any ther DOT drug/alchl regulatin?... Yes N T yur knwledge, has this driver vilated any DOT drug /alchl regulatin at a previus emplyer?... Yes N If the answer t any f the abve questins is Yes, please prvide details belw: Date f test(s): Reasn fr test(s): Result f test(s): If the applicant tested psitive, t yur knwledge, has he/she satisfactrily cmpleted all return-t-duty and fllw-up testing requirements in accrdance 49 CFR ?... Yes N Any ther remarks: Infrmatin prvided by (name & jb title): Date: PLEASE RETURN BY FAXING TO (570) ATTN: Terminal Cde First Request Date: / / Secnd Request Date: / / Third Request Date: / / Fax Mail Phne Fax Mail Phne Fax Mail Phne Attempt made by: Attempt made by Attempt made by: Rev. 8/15/2016 Reference Check Page 1 f 4

7 šre02gœ HireRight Custmer: Cmpany Name: Evans Delivery West Mtr TRUCKING INDUSTRY DOT D/A Disclsure and Authrizatin Send t Fax # (800) Cmpany Cntact Name: Fax #: (570) HireRight Acct Cde: EVANSD EFCO PART I DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49 CFR PART , DOT DRUG AND ALCOHOL TESTING In accrdance with DOT Regulatin 49 CFR Part , I hereby authrize release f my DOT-regulated drug and alchl testing recrds by the DOT-regulated emplyer(s) listed belw t HireRight fr the purpse f HireRight transmitting such recrds t the HireRight custmer listed abve. I understand that infrmatin/dcuments released pursuant t this Part I is limited t the fllwing DOT-regulated testing items, including pre-emplyment testing results, ccurring during the previus three (3) years: (i) alchl tests with a result f 0.04 r higher; (ii) verified psitive drug tests; (iii) refusals t be tested (including adulterated and/r substituted tests); (iv) ther vilatins f DOT drug and alchl testing regulatins (i.e., vilatins f 49 CFR 382 Subpart B); (v) infrmatin btained frm previus emplyers f a drug and alchl rule vilatin; and (vi) any dcumentatin f cmpletin f the return-t-duty prcess fllwing a rule vilatin. If any cmpany listed belw furnishes HireRight with infrmatin cncerning items (i) thrugh (vi) abve, I als authrize such cmpany t furnish the fllwing infrmatin t HireRight, if applicable: (i) dates f my negative drug and/r alchl tests and/r tests with results belw 0.04 during the previus three (3) years; and (ii) the name and phne number f any substance abuse prfessinal wh evaluated me during the previus three (3) years. List all DOT-regulated emplyers yu have applied with and/r wrked fr in a safety-sensitive functin during the previus three (3) years. If necessary, attach additinal pages, including the date, yur name, scial security number, and signature. Previus DOT-Regulated Emplyer City State Phne Number By signing belw, I certify that: (i) all infrmatin prvided herein is cmplete and accurate; (ii) I have read and fully understand this Part I disclsure and authrizatin fr release as well as the attached FMCSA Ntificatin f Driver Rights and any applicable state law ntices; (iii) prir t signing I was given an pprtunity t ask questins and t have thse questins answered t my satisfactin; (iv) I execute this authrizatin vluntarily and with the knwledge that the infrmatin btained pursuant t this authrizatin culd affect my eligibility fr emplyment, prmtin, retentin r ther lawful purpse; (v) I understand I may review this dcument with legal cunsel prir t signing; and v(i) facsimile r phtgraphic cpies f this authrizatin are as valid as an riginal. Print Applicant Name: Scial Security #: Applicant Signature: Date: Rev. 5/2/2016 Reference Check Page 2 f 4 (HireRight Page 1)

8 Part 2 FMCSA Ntificatin f Driver Rights šre03kœ In cmpliance with 49 CFR Part yu have certain rights regarding the safety perfrmance histry infrmatin that will be prvided t prspective emplyers.) Yu have the right t review infrmatin prvided by previus emplyers. II) Yu have the right t have errrs in the infrmatin crrected by the previus emplyer and fr that previus emplyer t re-send the crrected infrmatin t prspective emplyers. III) Yu have the right t have a rebuttal statement attached t the alleged errneus infrmatin, if the previus emplyer and the driver cannt agree n the accuracy f the infrmatin. (2) Drivers wh have previus DOT regulated emplyment histry in the preceding three years and wish t review previus emplyer-prvided investigative infrmatin must submit a written request t prspective emplyers. This may be dne at any time, including when applying, r as late as 30 days after being emplyed r being ntified f denial f emplyment. Prspective emplyers must prvide this infrmatin within five business days f receiving the written request. If prspective emplyers have nt yet received the requested infrmatin frm the previus emplyer, then the five day deadline will begin when the requested safety perfrmance histry infrmatin is received. If yu have nt arranged t pick up r receive the requested recrds within 30 days f prspective emplyers making them available, the prspective emplyers may cnsider yu t have waived yur request t review the recrd. A Summary f Yur Rights Under the Fair Credit Reprting Act Para infrmación en españl, visite escribe a la Cnsumer Financial Prtectin Bureau, 1700 G Street N.W., Washingtn DC The federal Fair Credit Reprting Act (FCRA) prmtes the accuracy, fairness, and privacy f infrmatin in the files f cnsumer reprting agencies. There are many types f cnsumer reprting agencies, including credit bureaus and specialty agencies (such as agencies that sell infrmatin abut check writing histries, medical recrds, and rental histry recrds). Here is a summary f yur majr rights under the FCRA. Fr mre infrmatin, including infrmatin abut additinal rights, g t r write t: Cnsumer Financial Prtectin Bureau, 1700 G Street N.W., Washingtn, DC Yu must be tld if infrmatin in yur file has been used against yu. Anyne wh uses a credit reprt r anther type f cnsumer reprt t deny yur applicatin fr credit, insurance, r emplyment - r t take anther adverse actin against yu - must tell yu, and must give yu the name, address, and phne number f the agency that prvided the infrmatin. Yu have the right t knw what is in yur file. Yu may request and btain all the infrmatin abut yu in the files f a cnsumer reprting agency (yur file disclsure ). Yu will be required t prvide prper identificatin, which may include yur Scial Security number. In many cases, the disclsure will be free. Yu are entitled t a free file disclsure if: a persn has taken adverse actin against yu because f infrmatin in yur credit reprt; yu are the victim f identity theft and place a fraud alert in yur file; yur file cntains inaccurate infrmatin as a result f fraud; yu are n public assistance; yu are unemplyed but expect t apply fr emplyment within 60 days. In additin, all cnsumers are entitled t ne free disclsure every 12 mnths upn request frm each natinwide credit bureau and frm natinwide specialty cnsumer reprting agencies. See fr additinal infrmatin. Yu have the right t ask fr a credit scre. Credit scres are numerical summaries f yur credit-wrthiness based n infrmatin frm credit bureaus. Yu may request a credit scre frm cnsumer reprting agencies that create scres r distribute scres used in residential real prperty lans, but yu will have t pay fr it. In sme mrtgage transactins, yu will receive credit scre infrmatin fr free frm the mrtgage lender. Yu have the right t dispute incmplete r inaccurate infrmatin. If yu identify infrmatin in yur file that is incmplete r inaccurate, and reprt it t the cnsumer reprting agency, the agency must investigate unless yur dispute is frivlus. See fr an explanatin f dispute prcedures. Cnsumer reprting agencies must crrect r delete inaccurate, incmplete, r unverifiable infrmatin. Inaccurate, incmplete r unverifiable infrmatin must be remved r crrected, usually within 30 days. Hwever, a cnsumer reprting agency may cntinue t reprt infrmatin it has verified as accurate. Cnsumer reprting agencies may nt reprt utdated negative infrmatin. In mst cases, a cnsumer reprting agency may nt reprt negative infrmatin that is mre than seven years ld, r bankruptcies that are mre than 10 years ld. Access t yur file is limited. A cnsumer reprting agency may prvide infrmatin abut yu nly t peple with a valid need -- usually t cnsider an applicatin with a creditr, insurer, emplyer, landlrd, r ther business. The FCRA specifies thse with a valid need fr access. Yu must give yur cnsent fr reprts t be prvided t emplyers. A cnsumer reprting agency may nt give ut infrmatin abut yu t yur emplyer, r a ptential emplyer, withut yur written cnsent given t the emplyer. Written cnsent generally is nt required in the trucking industry. Fr mre infrmatin, g t Rev. 5/2/2016 Reference Check Page 3 f 4 (HireRight Page 2)

9 Yu may limit "prescreened" ffers f credit and insurance yu get based n infrmatin in yur credit reprt. Unslicited "prescreened" ffers fr credit and insurance must include a tll-free phne number yu can call if yu chse t remve yur name and address frm the lists these ffers are based n. Yu may pt-ut with the natinwide credit bureaus at Yu may seek damages frm vilatrs. If a cnsumer reprting agency, r, in sme cases, a user f cnsumer reprts r a furnisher f infrmatin t a cnsumer reprting agency vilates the FCRA, yu may be able t sue in state r federal curt. Identity theft victims and active duty military persnnel have additinal rights. Fr mre infrmatin, visit šre04oœ States may enfrce the FCRA, and many states have their wn cnsumer reprting laws. In sme cases, yu may have mre rights under state law. Fr mre infrmatin, cntact yur state r lcal cnsumer prtectin agency r yur state Attrney General. Fr Infrmatin abut yur Federal rights cntact: TYPE OF BUSINESS 1.a. Banks, savings assciatins, and credit unins with ttal assets f ver $10 billin and their affiliates. 1.b. Such affiliates that are nt banks, savings assciatins, r credit unins als shuld list, in additin t the CFPB: CONTACT Cnsumer Financial Prtectin Bureau 1700 G Street NW, Washingtn, DC Federal Trade Cmmissin: Cnsumer Respnse Center FCRA Washingtn, DC (877) T the extent nt included in item 1 abve: 2.a. Natinal banks, federal savings assciatins and federal branches and federal agencies f freign banks 2.b. State member banks, branches and agencies f freign banks (ther than federal branches, federal agencies and Insured State Branches f Freign Banks), cmmercial lending cmpanies wned r cntrlled by freign banks, and rganizatins perating under sectin 25 r 25A f the Federal Reserve Act 2.c. Nnmember Insured Banks, Insured State Branches f Freign Banks, and insured state savings assciatins 2.d. Federal Credit Unins Office f the Cmptrller f the Currency Custmer Assistance Grp 1301 McKinney Street, Suite 3450 Hustn, TX Federal Reserve Cnsumer Help Center PO Bx 1200, Minneaplis, MN FDIC Cnsumer Respnse Center 1100 Walnut St., Bx #11, Kansas City, MO Natinal Credit Unin Administratin Office f Cnsumer Prtectin (OCP) Divisin f Cnsumer Cmpliance and Outreach (DCCO) 1775 Duke Street, Alexandria, VA Air carriers Asst. General Cunsel fr Aviatin Enfrcement & Prceedings, Aviatin Cnsumer Prtectin Divisin Department f Transprtatin 1200 New Jersey Avenue, S.E., Washingtn, DC Creditrs Subject t Surface Transprtatin Bard Office f Prceedings, Surface Transprtatin Bard Department f Transprtatin 395 E Street, S.W., Washingtn, DC Creditrs Subject t Packers and Stckyards Act, 1921 Nearest Packers and Stckyards Administratin area Supervisr 6. Small Business Investment Cmpanies Assciate Deputy Administratr fr Capital Access United States Small Business Administratin 409 Third Street, SW, 8th Flr, Washingtn, DC Brkers and Dealers Securities and Exchange Cmmissin 100 F Street, N.E. Washingtn, DC Federal Land Banks, Federal Land Bank Assciatins, Federal Intermediate Credit Banks and Prductin Credit Assciatins 9. Retailers, Finance Cmpanies, and All Other Creditrs Nt Listed Abve Farm Credit Administratin 1501 Farm Credit Drive McLean, VA FTC Reginal Office fr regin in which the creditr perates r Federal Trade Cmmissin: Cnsumer Respnse Center - FCRA Washingtn, DC (877) Rev. 5/2/2016 Reference Check Page 4 f 4 (HireRight Page 3)