Updated _Revised EDB Release Authorization Form_08-2020
RELEASE AUTHORIZATION Please check ONE of these boxes: I am an Entity. / (Print Name of Entity) EIN I am an Individual. / (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 reviewing applications for loans administered through the Economic Development Bank. 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supersede and countermand any prior authorization(s) to the contrary and shall remain in effect until such time as withdrawn in writing. …
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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. / (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 reviewing applications for loans administered through the Economic Development Bank. 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supersede and countermand any prior authorization(s) to the contrary and shall remain in effect until such time as withdrawn in writing.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 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. 08/2020)