CDLSuite | KBG Commercial Inc.

PSP Consent Form

authorization

KBG Commercial Inc.

Drivers have the following rights:

PSP Consent Form

authorization

Applicant Authorization Consent For Release of Information Form

Please provide the following information as well as addresses for the last seven (7) years.

KBG Commercial Inc.

KBG Commercial Inc.

Drivers have the following rights:

INQUIRY TO PAST EMPLOYER

Previous Employer Inquiry For Driving History & Safety Performance

Section 1 (Applicant)
Applicant Authorization

Section 2 (Previous Employer)
ACCIDENT HISTORY

Completed By

PSP Consent

The below disclosure and authorization language is for mandatory use by all account holders

Important disclosure regarding background reports from the psp online service

Other Disclosure and Authorization

OTHER DISCLOSURES, ACKNOWLEDGMENTS & AUTHORIZATIONS REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Acknowledgments & Authorization

ADDITIONAL STATE LAW NOTICE

Fair Credit Reporting Act Consumer Rights

A SUMMARY OF YOUR RIGHTS

UNDER THE FAIR CREDIT REPORTING ACT

Drivers Rights Pertaining to Release of Information
under Regulation 391.23

Join the family

Application For Employment

Commercial Driver's License

Driving/Hauling Experience

Education

Additional Licenses

Accident Review for Past 5 Years

Traffic Convictions & Forfeitures for Past 5 Years

Employment History

May we contact current employer?
Yes No

Authorization

Authorization to contact current employer?

Driving/Hauling Experience

May we contact current employer? Yes No

INQUIRY TO PAST EMPLOYER

Previous Employer Inquiry For Driving History & Safety Performance

Section 1 (Applicant) Applicant Authorization

Section 2 (Previous Employer) ACCIDENT HISTORY

Completed By

PSP Consent

The below disclosure and authorization language is for mandatory use by all account holders

Important disclosure regarding background reports from the psp online service

Applicant Authorization Consent For Release of Information

Authorization to contact current employer?

Other Disclosure and Authorization

OTHER DISCLOSURES, ACKNOWLEDGMENTS & AUTHORIZATIONS REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Acknowledgments & Authorization

ADDITIONAL STATE LAW NOTICE

Disclosure and Authorization

DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

DISCLOSURE

AUTHORIZATION

Pre-Employment Controlled Substance Consent Form

Pre-Employment Controlled Substance Consent Form

Fair Credit Reporting Act Consumer Rights

A SUMMARY OF YOUR RIGHTS

UNDER THE FAIR CREDIT REPORTING ACT

Drivers Rights Pertaining to Release of Information under Regulation 391.23

Consent for Limited Queries of the FMCSA Drug and Alcohol Clearinghouse

May we contact current employer?
Yes No

Section 1 (Applicant)
Applicant Authorization

Section 2 (Previous Employer)
ACCIDENT HISTORY

Drivers Rights Pertaining to Release of Information
under Regulation 391.23

*If at current address less than 7 years, list below most recent addresses for the past 7 years. (Click on the Plus sign to add additional Previous Addresses.)

DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES?

CAN YOU PROVIDE PROOF OF AGE?

HAVE YOU WORKED FOR THIS COMPANY BEFORE?

ARE YOU CURRENTLY EMPLOYED?

HAVE YOU EVER BEEN BONDED?

DO YOU HAVE ANY PHYSICAL CONDITION OR HANDICAP WHICH MAY LIMIT YOUR ABILITY TO PERFORM THE JOB APPLIED FOR?

ARE YOU PHYSICALLY CAPABLE OF HEAVY MANUAL WORK?

WERE YOU EVER INJURED ON THE JOB?

WOULD YOU BE WILLING TO TAKE A PHYSICAL EXAMINATION?

CDL Type *

Endorsements (check all that apply)

Air Brake Restriction? *

Automatic Transmission Restriction

Current DOT Medical Card *

Click on the Plus sign to add additional Accidents.

Click on the Plus sign to add additional Traffic Convictions or Forfeitures.

You must provide accurate dates of employment and phone numbers covering the last ten years (per DOT regulation). We cannot hire you without verifying employment. If you need to list additional employers, click "Add Another Employer" below.

Driving/Hauling Experience With This Employer

*If at current address less than 7 years, list below most recent addresses for the past 7 years. (Click on the Plus sign to add additional Previous Addresses.)

DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES?

CAN YOU PROVIDE PROOF OF AGE?

HAVE YOU WORKED FOR THIS COMPANY BEFORE?

ARE YOU CURRENTLY EMPLOYED?

HAVE YOU EVER BEEN BONDED?

DO YOU HAVE ANY PHYSICAL CONDITION OR HANDICAP WHICH MAY LIMIT YOUR ABILITY TO PERFORM THE JOB APPLIED FOR?

ARE YOU PHYSICALLY CAPABLE OF HEAVY MANUAL WORK?

WERE YOU EVER INJURED ON THE JOB?

WOULD YOU BE WILLING TO TAKE A PHYSICAL EXAMINATION?

CDL Type *

Endorsements (check all that apply)

Air Brake Restriction? *

Automatic Transmission Restriction

Current DOT Medical Card *

Click on the Plus sign to add additional Accidents.

Click on the Plus sign to add additional Traffic Convictions or Forfeitures.

You must provide accurate dates of employment and phone numbers covering the last ten years (per DOT regulation). We cannot hire you without verifying employment. If you need to list additional employers, click "Add Another Employer" below.

Driving/Hauling Experience With This Employer

From - Prospective Employer/Contractor	To - previous employer
Company : KBG Commercial Inc. Individual : Guadalupe Tamayo Address : 50 Inez Drive City : Bay Shore State : New York Zip : 11706	Company : Individual : Address : City : State : Zip :

Dear Motor Carrier:
The person listed below has made application to this company for employment or contracting as a Driver and states that he/she was employed by you as from to . If these dates are not correct please provide From and To The applicant has waived any claim of liability against you company for information submitted in response to the inquiry - See release form at bottom of this page

Name of Applicant:

Social Security Number of Applicant:

Date of Birth:

1. Is the employment record with your company, including dates, correct as stated above?

2. What kind of work did applicant do?

3. If employed as a driver, Specify type of equipment

4. If Tractor-Trailer please specify type: Dry Van Tanker Flatbed Reefer Dump Hopper

5. Total Miles Driven

6. Number of accidents Number preventable

7. Was applicant's drivers license ever suspended or revoked?

8. Reason for leaving your employ : Discharged Laid off Resigned

9. Was applicant's general conduct satisfactory? Yes No

10. Is applicant competent for the position applicant is seeking? Yes No

11. Would you re-employ? Yes No

12. Any remarks with regard to questions 1 - 11 above?

Signature of person supplying information

Date

I hereby authorize you to release all information regarding my services, character and conduct while in your employ, and you are released from any and all liablility which may result from furnishing such information.

Applicant's Signature

Date

Previous Employer:
Name:
Address:
Phone:
Email:
Fax:

Applicant
Applicant Name: Social Security: Date of Birth:

Date of Employment: From: To

Prospective Employer/Contractor:
KBG Commercial Inc.
50 Inez Drive Bay Shore New York 11706

Confidential Email: hr@kbgcommercial.com
Confidential Fax: 631-812-1489

Prospective Employer's/Contractor's Agent




Confidential Email:
Confidential Fax:

I, hereby authorize to release and forward the information requested in sections2 and 3 of this document concerning my Accident History within the previous 3 years to (Prospective Employer/Contractor), and/or (third-party investigation firm).

Applicant's Signature:

Date:

This information is being requested in compliance with 49 CFR $$ 40.25 and 391.23.

In compliance with 49 CFR $$40.25(g) and 391.23(h), release of this information must be made in a form that ensures confidentiality, such as fax, email, or letter.

The applicant named above was employed by you. Yes No

Employed as (Job Title)

From Date (mm/yyyy)

To Date (mm/yyyy)

Did he/she drive motor vehicle for you? Yes No

ACCIDENTS: Complete the following for any accidents included on your accident registrar ($390.15(b)) that involved the applicant in the 3 years prior to the application date shown above or check here if there is no accident register data for this driver.

Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:

Signature

Title

Date

Name:
Company:
Street:
City, State, Zip:
Phone:
Date:

In connection with your application for employment with , 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 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 and 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.

Name Signature: Date:

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

Investigative Consumer Report:
KBG Commercial Inc., (the “Company”) may request an investigative consumer report about you from , a consumer reporting agency, in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable). An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

Ongoing Authorization:
If the Company hires you or contracts for your services, the Company may obtain additional consumer reports and investigative consumer reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.

Additional State Law Notices:
Please see the “Additional State Law Notices” for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are provided below, as applicable.

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 , 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 (or from a consumer reporting agency other than ) 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.

□ California, Minnesota or Oklahoma consumers: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a free copy of your background report if one is obtained on you by the Company.

Please also note the following:

CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer reporting agency during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the actual copying costs, by appearing at the consumer reporting agency’s offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. The consumer reporting agency has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. “Proper identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, the consumer reporting agency may require additional information concerning your employment and personal or family history to verify your identity.

will prepare the background report for the Company. is located and can be contacted at , .

MASSACHUSETTS: Upon request to the Company, you have the right to know whether the Company requested an investigative consumer report about you and, upon written request to the Company, you have the right to receive a copy of any such report. You also have the right to ask the consumer reporting agency for a copy of any such report.

MINNESOTA: You have the right in most circumstances to submit a written request to the consumer reporting agency for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The consumer reporting agency must provide you with this disclosure within 5 days after (i) its receipt of your request or (ii) the date the report was requested by the Company, whichever date is later.

NEW JERSEY: You have the right to submit a request to the consumer reporting agency for a copy of any investigative consumer report the Company requested about you.

NEW YORK: You have the right, upon written request to the Company, to be informed of whether or not the Company requested a consumer report or an investigative consumer report about you. Shown above is the address and telephone number for , the consumer reporting agency used by the Company. You may inspect and receive a copy of any such report by contacting that consumer reporting agency

WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made to the Company within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You are entitled to this disclosure within 5 days after the date your request is received or the Company ordered the report, whichever is later. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Driver Name :
Signature :		Date :

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.

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. 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.
The following FCRA right applies with respect to nationwide consumer reporting agencies:
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.
As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.
A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.
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	a. Consumer Financial Protection Bureau 1700 G Street, N.W. Washington, DC 20552
b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:	b. Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580
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	a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050
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.	b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations	c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106
d. Federal Credit Unions	d. National Credit Union Administration Office of Consumer Financial Protection (OCFP) Division of Consumer Compliance Policy and Outreach 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., Suite 8200 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	Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W. Washington, DC 20580 (877) 382-4357

I acknowledge that I have read and understand the federal FCRA Summary of Rights and have been given the opportunity to copy/print the Summary of Rights and agree to use an electronic signature to demonstrate my consent.

Signature:

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

(a)(1) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those preceding three years.
(a)(2) An investigation of the driver's employment record during preceding three years.
(b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.
(c) Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.
(d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and accidents the previous employer may wish to provide.
(e) Prospective motor carriers must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

The right to review information provided by previous employers
The right to have errors in the information corrected by the previous employer and for that employer to resend the corrected information to the prospective employer
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.

Drivers who wish to review previous employer-provided information must submit a written request to the prospective employer when applying of as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days pf the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instructions to include the rebuttal in the driver's Safety Performance History.

I acknowledge that I have read and understand the contents of this document.

Signature:

Date:

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