Authorization to Conduct Credit Check
Borrower
Full name--include generations (Jr., Sr., III): ______________________________________
Other names used: ______________________________________
Street address: ______________________________________
City, state, and zip code: ______________________________________
Date moved into current address: ________________
Previous address: ______________________________________
City, state, and zip code: ______________________________________
Dates there: ______________________________________
Home phone: ___________________	Social Security number: __________________
Date of birth: ________________
Driver's license number: _________________
Employment History 
Name and address of current employer: ________________________________________
Name of supervisor: ___________________________________
Supervisor's phone: ______________________	Annual gross income: ____________
Credit and Financial Information
Bank/Financial accounts	Account number	Bank/Institution	Branch
Bank savings account:	
Bank checking account: 	
Bank certificate of deposit:	
Mutual fund account: 	
Brokerage account: 	
Other:	

Credit accounts & loans	Type of account	Account	Name of	Amount	Monthly
	(auto loan, Visa, etc.)	number	creditor	owed	payment
Credit card: 	
Loan (specify type): 	
Loan (specify type): 	
Loan (specify type): 	
Other (specify type): 	

I certify that all the information given above is true and correct. I authorize verification by my credit sources and employer of the information provided.

________________________________________	________________
Signature of Borrower	Date