Name of applicant: Enter the name of the applicant

Social security number: Enter the social security number of applicant

Date of application: Enter the date of the application

TO: Employers, Credit References

You are authorized to release information concerning my employment or credit history with you to Enter the name of prospective creditor.

You are further released from liability in connection with your response to this inquiry.

A photocopy of this authorization will be as effective as an original.

___________________________________________

Enter the name of the applicant

Enter the name of prospective creditor

Attention: Enter name of person to reply to at creditor

Enter the street address of the prospective creditor

Enter the city, state of the prospective creditor

Telephone: Enter the telephone number of prospective creditor