Revised VIEDC Release Authorization Form_01272017
RELEASE AUTHORIZATION Please check ONE of these boxes: 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 (“VIEDA”) to conduct a full background investigation. …
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RELEASE AUTHORIZATION Please check ONE of these boxes: 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 (“VIEDA”) to conduct a full background investigation. I hereby authorize VIEDA 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 VIEDA to perform background investigations for the purpose of processing applications for tax incentives administered through the Virgin Islands Economic Development Commission. 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supersede and countermand any prior authorization(s) to the contrary and shall remain in effect until such time as withdrawn in writing.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 ____________________________________________________ ) ) COUNTY OR DISTRICT OF ________________________________________ ) SS: 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. 01/2017)