CONTACT US TODAY:
330-448-4046
800-446-8785
E-MAIL

  • Nick Strimbu, Inc.
  • Nick Strimbu, Inc.
  • Nick Strimbu, Inc.
  • Nick Strimbu, Inc.
  • Nick Strimbu, Inc.
  • Nick Strimbu, Inc.

Employment Application

Please fill in the form below as completely as possible.


 

MINIMUM QUALIFICATIONS:
  • CDL Class "A" and be 22 years old or older
  • 1 year verifiable over the road tractor trailer experience
  • Limited number of entry level positions available
  • Current DOT physical
  • Be able to successfully complete drug and alcohol screen
  • Be able to successfully pass road test
  • Must possess a good track record of on-time deliveries and reliability
  • Must have a steady work history averaging 1 year or more at jobs in the last 4 years
  • No DUI, OWI, reckless driving, or other major moving violations
  • Less than 2 instances in any 12 month period
  • Less than 3 instances in any 36 month period (An instance is a moving violation or preventable accident)
  • No more than 1 preventable accident in any 36 month period
Minimum qualifications are subject to change without notice.
 

 
First Name:
Middle Name:
Last Name:
Previous Names or Aliases:
Street Address:
City:
State:
Zip Code:
How long have you lived at this address?
Home Phone Number:
Cell Phone Number:
E-mail Address:
What is the best time to reach you?

Emergency Contact Information

Emergency Contact Name:
Emergency Contact Phone Number:
Relation to You:
Occupation:

Education

Select highest grade completed:
Last School Attended:
School Address:

General Employment

Position Desired:
Have you ever applied to Nick Strimbu Inc. before?
Yes   No
Have you ever worked for Nick Strimbu Inc. before?
Yes   No
If so, work dates:
/  to  /
Position:
Reason for Leaving:
Names of any relatives working here:
Did someone refer you?
Yes   No
Referrer Name:
Have you ever been convicted of a felony?
Yes   No
If YES, please explain fully. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
Do we have permission to run your Motor Vehicle Report?
Yes   No
How did you hear about Nick Strimbu Inc.?

In order to complete this inquiry, the following information is required:

Birth Date
/ /
Social Security Number (omit hyphens)"
Drivers License Number:
Issuing State:
Do you have a current CDL License?
Yes   No
This job requires lifting 75 lbs. over your head. Are you able to meet these physical requirements?
Yes   No
How many employers have you worked for in the last 5 years?
Years of commercial driving experience:

Current & Previous Employers

List all employers for the last three (3) years and any employment as a commercial vehicle operator for the last ten (10) years. Do not leave any gaps.

Current Employer:
Start Date:
Employer Street Address:
Employer City:
Employer State:
Employer Zip Code:
Employer Phone Number:
Position:
Equipment Pulled:
Number of Accidents:
Rate of Pay:
May we contact your current employer?
Yes   No
Contact Person:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?
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

Previous Employer #1:
Start Date:
End Date:
Previous Employer Street Address:
Previous Employer City:
Previous Employer State:
Previous Employer Zip Code:
Previous Employer Phone Number:
Position:
Equipment Pulled:
Number of Accidents:
Rate of Pay:
Reason for Leaving:
May we contact your previous employer?
Yes   No
Contact Person:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?
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

Previous Employer #2:
Start Date:
End Date:
Previous Employer Street Address:
Previous Employer City:
Previous Employer State:
Previous Employer Zip Code:
Previous Employer Phone Number:
Position:
Equipment Pulled:
Number of Accidents:
Rate of Pay:
Reason for Leaving:
May we contact your previous employer?
Yes   No
Contact Person:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?
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

Previous Employer #3:
Start Date:
End Date:
Previous Employer Street Address:
Previous Employer City:
Previous Employer State:
Previous Employer Zip Code:
Previous Employer Phone Number:
Position:
Equipment Pulled:
Number of Accidents:
Rate of Pay:
Reason for Leaving:
May we contact your previous employer?
Yes   No
Contact Person:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?
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

Previous Employer #4:
Start Date:
End Date:
Previous Employer Street Address:
Previous Employer City:
Previous Employer State:
Previous Employer Zip Code:
Previous Employer Phone Number:
Position:
Equipment Pulled:
Number of Accidents:
Rate of Pay:
Reason for Leaving:
May we contact your previous employer?
Yes   No
Contact Person:
Were you subject to the Federal Motor Carrier Safety Regulations while employed by this employer?
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

Experience

List all your experience in the operation of motor vehicles (reefer, flatbed, 20', 40', 45', straight truck, etc.)

Type of Equipment:

Number of Years:

Number of Miles:

Type of Equipment:

Number of Years:

Number of Miles:

Type of Equipment:

Number of Years:

Number of Miles:

Type of Equipment:

Number of Years:

Number of Miles:


Accidents

List ALL accidents involving a motor vehicle in the past three (3) years.
No accidents? Click the button here.
NONE

Accident #1 Date:

Vehicle Type:

Accident Type:

Chargeable?
Yes   No

Number of Injuries/Fatalities:

Accident #2 Date:

Vehicle Type:

Accident Type:

Chargeable?
Yes   No

Number of Injuries/Fatalities:

Accident #3 Date:

Vehicle Type:

Accident Type:

Chargeable?
Yes   No

Number of Injuries/Fatalities:

Accident #4 Date:

Vehicle Type:

Accident Type:

Chargeable?
Yes   No

Number of Injuries/Fatalities:


Traffic Convictions

List ALL convictions for moving violations in the past three (3) years.
No convictions? Click the button here.
NONE

Conviction #1 Date:

Charge:

Town/State:

Vehicle Type:

Conviction #2 Date:

Charge:

Town/State:

Vehicle Type:

Conviction #3 Date:

Charge:

Town/State:

Vehicle Type:

Conviction #4 Date:

Charge:

Town/State:

Vehicle Type:


Professional Information

List all licenses held in the last three (3) years.

License Number:

State:

Turned in?
Yes   No

License Number:

State:

Turned in?
Yes   No

License Number:

State:

Turned in?
Yes   No

License Number:

State:

Turned in?
Yes   No

1. Are you currently qualified to drive a commercial motor vehicle?
Yes   No
2. Within the previous three (3) years have you violated the alcohol and controlled substance prohibitions under subpart B of 362 FMCSR or 49CFR part 40?
Yes   No
3. Have you ever been convicted of a crime or narcotic offense?
Yes   No
4. Has your license been suspended or revoked in the last five (5) years?
Yes   No
5. Have you ever been discharged for equipment abandonment?
Yes   No
6. Have you ever left the scene of an accident?
Yes   No
If "Yes" to questions 2-6, please explain:

It is agreed and understood that Nick Strimbu Inc. (NSI) insurance company and/or NSI’s insurance agent may investigate the Applicant’s background in accordance with Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508 as amended by the Consumer Credit Reporting Act Of 1996(Title II, Subtitle 0 Chapter Of Public Law 104-208). You are being informed that reports verifying your previous employment, previous drug, and alcohol test results, and your driving record will be obtained on you for employment purposes, for use in rating and/or underwriting insurance for which NSI may apply,and any renewal thereof. These reports are required by Sections 382.413, 391.23,and 391.25 of the Federal Motor Carrier Safety Regulations. NSI will investigate the applicant’s background to ascertain any and all information of concern to applicant’s record whether same is of record or not and applicant releases NSI and agencies supplying this information from any and all liabilities on account of furnishing such information. The applicant agrees to furnish such additional information and complete such examination as necessary to complete required files. It is agreed and understood that this application in no way obligates NSI to employ/lease the applicant. It is agreed and understood that if employed/leased such employment/lease is terminable at will. No company policy or procedure shall be deemed to vest any right with any person to create or guarantee employment/lease for any period of time or to create or contribute in any way toward a legal cause of action against NSI. In the case of an independent contractor, nothing in the application or agreement shall be used to establish an employer/employee relationship.

I certify that this application was completed by me (applicant) and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that intentional falsification of information on this application will be grounds for immediate termination.

I certify that I have read and understand the release printed above. I also understand that by signing this application I agree to comply with the hiring criteria printed on the first page of this application. I understand that failure to comply with these criteria will be considered a violation of company work rues and could be grounds for termination.

By clicking this box, you acknowledge the above statements and accept this as a digital signature that is legal and binding without exception.


Have you ever tested positive, or refused to test, on any pre-employment or other drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work or that you were employed by who was covered by DOT agency drug and alcohol testing rules?
Yes   No

THANK YOU FOR APPLYING WITH NICK STRIMBU INC.

IMPORTANT—PLEASE READ FIRST!!!!

In order to process your application in a timely manner, it is necessary for you to sign the following documents along with your application as quickly as possible:

1. INQUIRY TO PAST EMPLOYERS: Please sign and date where marked. DO NOT fill out the rest of the form. This sheet is used to collect information from your past employers per DOT regulations. This form is kept in your Qualification file. ALL GAPS OF UNEMPLOYMENT MUST BE VERIFIED.

2. AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION: This Form grants Nick Strimbu Inc. the right to run a Motor Vehicle Report and receive any public information in regards to your employment with Nick Strimbu, Inc.

3. DRIVERS RIGHTS: As a driver you are provided with certain rights under the Federal Motor Carrier Safety Regulations. This document is to inform you of those rights. Please sign where marked.


Inquiry to Past Employer

Nick Strimbu Inc. · 3500 Parkway Dr. · Brookfield, OH 44403 · Phone 330-448-4046 · Fax 330-448-4106

Applicant’s Name:
Social Security Number:

You are hereby authorized to give to Nick Strimbu, Inc. (NSI) all information regarding my services, character and conduct while in your employ, and you are released from liability that may result from giving such information. In order to enable NSI to comply with the requirements of 49CFR,382.413 & 391.23, I hereby consent to NSI obtaining from my prior employers the information pertaining to me which they are required to maintain by 49 CFR 382.401 (b) (I) (I) through (III) regarding alcohol tests with a concentration result of0.04 or greater, positive controlled substance test results and refusal to be tested within the three (3) years preceding the date of this application and 49 CFR 391.23(a)2 & (d) investigation of my past employment record. I hereby authorize and direct my prior employers to release such information to NSI in personal interviews, telephone interviews, letters or any other method that insures confidentiality. I hereby authorize NSI to release such information to any of its personnel whose duties require them to access this application or to make any recommendations or decisions with respect to it.

By clicking this box, you acknowledge the above statements and accept this as a digital signature that is legal and binding without exception.

 

NOTE: This section below for office use only. Do not fill in. —

Name of Company:

Phone Number:

Street Address:

E-mail Address:

City:

State:

Zip:

Period of Employment:
to

Position Held:

Driver?
Yes   No    

Driver Status:

Equipment:

List areas in which applicant drove regularly:

Logs: Did applicant violate hours of service regulations?
Yes   No

Accidents - Total Number:

D.O.T. Reportable Accidents:

Tickets?
Yes   No

Describe:

What license did applicant have?
Class:
State of Issue:

Why did applicant leave your employ?

Is applicant eligible for rehire?
Yes   No

If no, why?

Was applicant’s license ever suspended or revoked?
Yes   No

In accordance with part 382.405, 382.413, and 40.25:

Has this person ever tested positive for a controlled substance in the past three years?
Yes   No

Has this person ever had an alcohol test concentration of 0.04 or greater in the past three years?
Yes   No

Has this person ever refused a required test for drugs or alcohol in the past three years?
Yes   No

Has this person violated any other DOT agency drug and alcohol testing regulations?
Yes   No

Additional comments:

Signature:

Title:

Date:


FAIR CREDIT REPORTING ACT DISCLOSURE NOTICE AND AUTHORIZATION FORM

Definitions you will want to understand before signing this form include:

Employment purposes
When used in connection with a consumer report, this term means a report used for the purpose of evaluating a consumer for employment, promotion, reassignment, or retention as an employee.

Adverse action
A denial of employment or any other decision for employment purposes that adversely affects any current or prospective employee.

Consumer report
Any written, oral, or other communication of any information by a consumer reporting agency bearing on the consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing the consumer’s eligibility for employment purposes.

Investigative consumer report
A consumer report or portion thereof in which information on a consumer’s General reputation, personal characteristics, or mode of living is obtained the personal interviews with neighbors, friends, or associates of the consumer r with others with whom he is acquainted or who may have knowledge concerning such items of information. However, such information shall not include specific information on a consumer’s credit record obtained directly from a creditor consumer or from a consumer reporting agency when such information was directly from a creditor of the consumer.

Please take notice that one or more consumer reports may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, as amended, 15 U.S.C. §1681, et seq. Should a decision to take any adverse action against you be made, based either in whole or in part on the consumer report, the consumer reporting agency that provided the report played no role in our decision to take such adverse action.

Information provided by you on this form will be furnished to Hire Right Inc, 5151 California Ave., Irvine, CA 92617 in order to obtain information in connection with an investigation to determine your (I) fitness for employment, (2) clearance to perform contractual service for our company, and/or (3) security Clearance or access. Reports verifying your driving record, previous employment verifications, DAC, COLIS, drug and alcohol results and background checks may be obtained on you for employment purposes. These reports are required by 49 Code of Federal Regulations Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. You have a right to request a complete and Accurate disclosure of the nature and scope of any investigative consumer report requested. In addition, you have a right to a written summary of your rights under §168lg of the Fair Credit Reporting Act, as amended.

I hereby authorize Nick Strimbu Inc. to obtain such report(s) from Hire Right Inc. for employment purposes.

Name:
Social Security Number:

Your Social Security Number is needed to keep records accurate, because other people may have the same name.

By clicking this box, you acknowledge the above statements and accept this as a digital signature that is legal and binding without exception.

 


HireRight. DAC Trucking

TRUCKING INDUSTRY: DOT D/A Disclosure and Authorization

PART 1—DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES- 49 CFR PART 391.23. DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information / documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and / or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vQ 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, Ialso 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 #1:

City:

State:

Phone Number:

Previous DOT-Regulated Employer #2:

City:

State:

Phone Number:

Previous DOT-Regulated Employer #3:

City:

State:

Phone Number:

Previous DOT-Regulated Employer #4:

City:

State:

Phone Number:

Previous DOT-Regulated Employer #5:

City:

State:

Phone Number:

Previous DOT-Regulated Employer #6:

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; (iii) 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.

Name:
Social Security Number:

By clicking this box, you acknowledge the above statements and accept this as a digital signature that is legal and binding without exception.

DOT Drug/Alcohol Disclosure/Authorization Trucking Industry - Employment Purpose. UPDATED 4/10


Authorization of Background Investigation

I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, Consent to preparation of background reports by a consumer reporting agency such as HireRight, Inc. ("HireRight"), and to the release 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 (including independent contractor 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 additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period from HireRight and/or other consumer reporting agencies.

I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract 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 hearby authorize all of the following, without limitation, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present 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 history, motor vehicle history, criminal history, military service, professional credentials and licenses.

By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company.

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

Applicant First Name:
Applicant Middle Name:
Applicant Last Name:

By clicking this box, you acknowledge the above statements and accept this as a digital signature that is legal and binding without exception.

 


PART 2—FMCSA NOTIFICATION OF DRIVER RIGHTS

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


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

A Summary of Your Rights under the Fair Credit Reporting Act

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

  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment—or to take another adverse action against you—must tell you, and must give you the name, address, And phone number of the agency that provided the information.
     
  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
     
    • a person has taken adverse action against you because of information in your credit report;
    • you are the victim of identity theft and place a fraud alert in your file;
    • your file contains inaccurate information as a result of fraud;
    • you are on public assistance;
    • you are unemployed but expect to apply for employment within 60 days.
       
  • In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
     
  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit- worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
     
  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
     
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
     
  • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
     
  • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
     
  • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
     
  • You 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, yon 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
P.O. Box 1200
Minneapolis, MN 55480

c. FDIC Consumer Response Center
1100 WalnutSt., Box fll1
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, 8th Floor
Washington, DC 20416


7. Brokers and Dealers

Securities and Exchange Commission
100 F Street, N.E.
Washington, DC 20549


8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks and Production Credit Associations

Fann 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


(NEW JERSEY APPLICANTS ONLY)
A Summary of Your Rights
Under New Jersey’s Fair Credit Reporting Act

Under the New Jersey Fair Credit Reporting Act (NJFCRA or the "Act"), an employer, before taking adverse employment action, is required to provide the applicant or employee with a summary of their rights under the Act with respect to consumer reports or investigative consumer reports obtained for employment purposes from a consumer reporting agency (CRA). This Summary is intended to serve that purpose.

You can find the complete text of the NJCRA, N.J. Stat. §§56:11-29- 56:11-41, at the New Jersey State Legislature’s web site (http://www.njleg.state.nj.us). You may have additional rights under the federal Fair Credit Reporting Act, 15 U.S.C. 1681-1681u, which is available on the Internet at the Federal Trade Commission’s website (http://www.ftc.gov).

  • You must consent to the procurement for employment purposes of a report about you. Before an employer can obtain a report about you from a CRA, the employer must provide you with notice that it will request the report and obtain your consent to that request. A CRA may not give out information about you to your employer, or prospective employer, without your written consent.
     
  • You must be told if information in your file has been used against you for employment purposes. An employer who uses information from a consumer or investigative consumer report to take action against you—such as denying an application for employment or terminating employment—must tell you that its decision is based in whole or in part on the report. The employer also must provide you with a description of your rights under the NJCRA and a reasonable opportunity to dispute with the CRA any information on which the employer relied.
     
  • You can find out what is in your file. At your request, a CRA must give you the information in your file and a list of everyone who has recently requested your file. These disclosures may be made in person, over the telephone or by any other reasonable method available to the CRA.
     
  • You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must reinvestigate the disputed items, free of charge, within 30 days, unless the CRA determines that the dispute is frivolous or irrelevant. The CRA must give you a written report of the investigation. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
     
  • Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files within 30 days after you dispute it. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the business name and address.
     
  • You may seek damages from violators. If a CRA user or (in some cases) a provider of CRA data violates the NJFCRA, you may sue them in state court.
     

(NEW YORK APPLICANTS ONLY)
NEW YORK CORRECTION LAW
ARTICLE 23-A

LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES

Section 750. Definitions.

751. Applicability.

752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.

753. Factors to be considered concerning a previous criminal conviction; presumption.

754. Written statement upon denial of license or employment.

755. Enforcement.


§750. Definitions. For the purposes of this article, the following terms shall have the following meanings:

(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.

(2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons.

(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.

(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.

(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.

§751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.

§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual’s having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such fmding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless:

(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or

(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.

§753. Factors to be considered concerning a previous criminal conviction; presumption.

1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors:

(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses.

(b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person.

(c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.

(d) The time which has elapsed since the occurrence of the criminal offense or offenses.

(e) The age of the person at the time of occurrence of the criminal offense or offenses.

(f) The seriousness of the offense or offenses.

(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.

(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public.

2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which Certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.

§754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.

§755. Enforcement.

1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.

2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.