Date:_____________   2019

 

 

 

 

 

AUTHORIZATION RELEASE –

 For Personal Data Record Information

 

 

 

To Whom It May Concern:

 

I hereby authorize and request any employer, police department, law enforcement, credit bureau, financial institution and any and all persons having personal knowledge aboutme, to furnish the bearer of this release with the answers to any information within their knowledge regarding me.

 

I agree to hold any and all parties blameless and free of any liability for releasing any truthful information that is within their knowledge or records.

 

I am willing to have a photocopy of this authorization be accepted with the same authority as the original.

 

Based upon this authorization request I waive any written notice from a present or former employer.

 

 

 

 

Last Name:  __________________________   First Name:_________________________________   MI: ___________     

 

Social Security Number:_______________________________   Date of Birth: ________________________________                        

 

Driver’s License or ID Number:________________________________________________________________________                                                                                                                                            

 

Current Address:  __________________________________________   Apt# _________________________________                   

 

City: _________________________________________   State:_____________________   Zip Code: ______________         

 

Property Value/Purchase Price: ________________________  Loan Amount:_________________________________

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Bedrooms in the Property:_________ Bathrooms in the Property:_____________ Sq. Ft. of Property:___________           

 

Home Phone Number: ________________________   Name this phone is listed under:_______________________                                            

 

Cell Phone Number: _______________________   Name this phone is listed under:__________________________                                                    

 

Email _______________________________________.

 

 

Have you ever been a plaintiff or defendants in any court of law?_____ If YES, please explain. 

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Print Name: ____________________________________

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Signature: ______________________________________

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Please return this application via email or take a picture with your phone and send it to the following:

RGEEE@AOL.COM & X.UNYPO@GMAIL.COM and You can Text a Photo of this Application to 646-345-1869

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