DISCLOSURE REGARDING BACKGROUND INVESTIGATION

1 DISCLOSURE AND RELEASE OF INFORMATION AUTHORIZATION I authorize BNSF Railway Company and First Advantage, a consumer reporting agency, to retrieve information from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the federal, state (including the Minnesota Bureau of Criminal Apprehension), or county level, worker s compensation agencies or individuals relating to my past activities, to supply any and all information concerning my BACKGROUND and release from any liability resulting in providing such information.

2 The information received may include but is not limited to academic, residential, achievement, job performance, attendance, litigation, personal history, credit reports, driving history, worker s compensation records (including medical information) and criminal history records. I understand that a consumer report may be prepared summarizing this information. If my prior employers and/or references are contacted, the report may include information obtained through personal interviews REGARDING my character, general reputations, personal characteristics and/or mode of living.

3 I may request a copy of any report that is prepared REGARDING me and may also request the nature and substance of all information about me contained in the files of the consumer reporting agency. I understand that proper identification will be required and that I should direct my request to: First Advantage, Box 105108, Atlanta, GA 30348. Phone: (800) 845-6004 If applying for employment in Minnesota, Oklahoma or California, a copy of the consumer report will be automatically sent to the address on your application.

4 By my signature below, I hereby release any information or institution including its officers, employees, or related personnel both individually and collectively from any and all liability for damages of whatever kind, which may result to me because of compliance with this authorization and request to release information or any attempt to comply with it. I hereby authorize First Advantage to release to BNSF Railway Company any documentation or information I provide directly to First Advantage in connection with my application for employment.

5 I hereby certify that all statements and answer set form on the application form and/or my resume are true and complete to the best of my knowledge and I understand that if subsequent to employment and such statements and/or answers are found to be false or that information has been omitted, such false statements or omissions will be just cause for the termination of my employment. I agree that a photocopy of this authorization be accepted with the same authority as the original and this release expires one year after the date of origination.

6 _____ SIGNATURE DATE NOTE: The following information is provided voluntarily and IS NOT considered as part of your application for employment. It is used only for identification purposes in verifying information on your Employment Application. PLEASE PRINT CLEARLY. Last Name First Name Middle Name Street Address City State Zip Driver s License No. State of Issuance Expiration Date List any CITIES and STATES in which you have lived during the previous 7 years.

7 List any NAMES you have used during the previous 7 years. List any NAMES under which you received your GED, high school diploma or other degrees. FMCSA - 1 Rev 8/28/12 FMCSA Safety Sensitive Authorization for Applicant or Employee Safety Performance History including Alcohol and Controlled Substances History As Required by the US Department of Transportation, Regulation 49 CFR Part and the Federal Motor Carrier Safety Administration Regulations, Section Section A. As your employer or prospective employer, we are required by the US Department of Transportation (DOT) under Regulation 49 CFR Part 40 to ask the following question before we can place you in a DOT-regulated safety-sensitive position.

8 Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years? YES NO Section B. List a DOT-regulated employer for whom you have worked in the previous three (3) years (including part-time) on the line provided. If this does not apply to you, check the box immediately below the line.

9 If you have worked for more than one DOT-regulated employer in the previous three (3) years, you will need to disclose each employer on a separate form. _____ I have not worked for any DOT-regulated employer in the previous three (3) years. Section C. Applicants who have previous DOT-regulated employment history in the preceding three (3) years, and wish to review previous employer -provided investigative information must submit a written request to the prospective employer, which 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.

10 The prospective employer must provide t his information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the applicant has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the applicant to have waived his/her request to review the records.