HireRight Customer:

Company Name: Naegeli Transportation Inc.

Company Contact Name: Ellen Naegeli

Fax #: (713) 946 3000

HireRight Account Code: _____________________________

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 #:
Date
Applicant Signature:

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.

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

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.

I hereby authorize Company to obtain the consumer reports described above about me.

Applicant Name:
Applicant Signature:	Date

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

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

DATE TERMINATED	DEPARTMENT RELEASED FROM
DISMISSED VOLUNTARILY QUIT OTHER
TERMINATION REPORT PLACED IN FILE	SUPERVISOR

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? YES NO

Have you ever service the United States armed forces?If yes, indicated which branch of service you served in

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]?          YES NO  If no explain: Have you ever been convicted of a felony? YES NO  If yes explain:

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? YES NO
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? YES NO

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? YES NO
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? YES NO

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? YES NO
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? YES NO

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? YES NO
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? YES NO

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? YES NO
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? YES NO

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? YES NO
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? YES NO

* 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

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

CLASS OF EQUIPMENT		CIRCLE TYPE OF EQUIPMENT	DATES FROM(M/Y) TO(M/Y)		APPROX. NO. OF MILES (TOTAL)
STRAIGHT TRUCK	YES NO	(VAN,TANK,FLAT,DUMP,REFER)
TRACTOR AND SEMI-TRAILER	YES NO	(VAN,TANK,FLAT,DUMP,REFER)
TRACTOR - TWO TRAILERS	YES NO	(VAN,TANK,FLAT,DUMP,REFER)
TRACTOR - THREE TRAILERS	YES NO	(VAN,TANK,FLAT,DUMP,REFER)
MOTORCOACH - SCHOOL BUS	YES NO
OTHER

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

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. YES NO
Employed as (job title) from (m/y) to (m/y)
Did he/she drive a motor vehicle for you? YES NO If yes, what type? Straight Truck Tractor-Semitrailer Bus
Cargo Tank Doubles/Triples Other (Specify)
Completed by
Company:
Street:
City, State, Zip: Telephone:
Signature: Date:
If there is no safety performance history to report, check here and return. Otherwise, complete Sections 3 and 4 on SIDE 2 before returning.
-

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 if there is no accident register data for this driver.
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 , and return.
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: YES NO
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)?   YES NO N/A     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? YES NO N/A

SECTION 5a:	TO BE COMPLETED BY PROSPECTIVE EMPLOYER
This form was (check one) Faxed to previous employer. Mailed. Emailed. Other
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: Fax Mail Email Telephone
Date: Other

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 may 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 - 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, 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