VIEDA Release Authorization Form_Revised 06-2024 FINAL Fillable
RELEASE AUTHORIZATION Please select ONE of the following options: I am an Entity. / (Print Name of Entity) EIN I am an Individual holding five percent (5%) or more ownership interest in the entity. / (Print Name of Individual) SSN As the above-referenced individual or duly authorized representative of the entity, I hereby authorize the Virgin Islands Economic Development Authority (“USVIEDA”) to conduct a full background investigation. I hereby authorize USVIEDA or its designees to submit this Release Authorization (“Release”) to all courts, probation offices, Selective Service Boards, employers, credit agencies, educational institutions, banks, financial and other institutions, and all governmental agencies or other entities -- federal, state and local, both foreign and domestic -- as may be required by USVIEDA to perform background investigations for the purpose of processing applications for tax incentives administered through the Virgin Islands Economic Development Authority. …
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RELEASE AUTHORIZATION Please select ONE of the following options: I am an Entity. / (Print Name of Entity) EIN I am an Individual holding five percent (5%) or more ownership interest in the entity. / (Print Name of Individual) SSN As the above-referenced individual or duly authorized representative of the entity, I hereby authorize the Virgin Islands Economic Development Authority (“USVIEDA”) to conduct a full background investigation. I hereby authorize USVIEDA or its designees to submit this Release Authorization (“Release”) to all courts, probation offices, Selective Service Boards, employers, credit agencies, educational institutions, banks, financial and other institutions, and all governmental agencies or other entities -- federal, state and local, both foreign and domestic -- as may be required by USVIEDA to perform background investigations for the purpose of processing applications for tax incentives administered through the Virgin Islands Economic Development Authority. This Release shall supersede and countermand any prior authorization(s) to the contrary and shall remain in effect until such time as withdrawn in writing. _________________________ __________________________ ________________________ Signature Print Name Title _________________________ __________________________ ________________________ Date of Birth Place of Birth Telephone Number _________________________ _________________________________________________________ Email Address Current Physical Address (including City, State, Zip Code) ACKNOWLEDGMENT STATE OF __________________________ ) ) SS: COUNTY OR DISTRICT OF______________ ) On this _________day of _____________________, 20____, before me the undersigned officer, personally appeared________________________________________, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that he/she is authorized to execute same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. _______________________ Notary Public Commission Expires: A photocopy, electronic, or similar copy of this Release shall be considered as effective and valid as the original. (Rev. 06/2024) SIGN