Consumer Authorization and Release

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Applicant First Name:

Middle Initial:

Last Name:

Social Security Number:

Date of Birth:

Current Address:

How long at current address?

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Co-Applicant Name:

First Name:

Middle Initial:

Last Name:

Social Security Number:

Date of Birth:

Current Address:

How long at current address?

I/We hereby authorize

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Inc. to obtain my/our consumer report/credit information, credit risk scores and other enhancements to my/our consumer report (hereinafter collectively referred to as “Report”) from one or more of the three national credit reporting repositories (Equifax, Experian, Trans Union) and provide a copy of the Report to:

New Field:

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, Inc. for the purpose of assessing my/our Application for Membership in said ROC. I/We understand that ‘other enhancements’ includes conducting a national criminal background check, to which I/we give my/our consent.

This authorization is intended to comply with a consumer report request as set forth in 15 U.S.C. 1681b(a)(2).

I/WE further authorize the

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, Inc. to contact the references listed on my/our application in order to assess my/our Application for Membership in said ROC.

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It is understood that a photocopy and/or facsimile of this document shall also serve as an authorization to provide the information requested.

The information obtained is only to be used in the processing of my/our Membership

Application.

Applicant

Date

Co-applicant

Date

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