Authorization for Credit Report

Full Name*

First name/Middle InitialLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Please enter a valid phone number.

Secondary Phone Number

Please enter a valid phone number.

Email*

example@example.com

Social Security Number

Address if less than 3 years at current address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

This is to certify that / am or will be applying for credit from the Quaboag Valley Business Assistance Corporation and that / hereby authorize an investigation of my credit, both personal and business, as a necessary part of the application process. I give permission to also obtain credit reports in connectionwith the same transfer or extension of credit, for the purpose of reviewing the account, increasing the credit line on the account, for the purpose of taking collection action on the account, or for other ligimate purposes associated with the account.

Signature*

Date*

23 West Main Street, Suite 1 Ware, MA 01082

413-967-3001 . Fax 413-967-3008 . mail@qvcdc.com

Serving the towns of Belchertown - Brimfield . Brookfield . Charlton - Dudley . East Brookfield Hardwick . Holland Monson New Braintree . North Brookfield . Oxford Palmer . Spencer Southbridge . Sturbridge Wales . Ware . Warren . West Brookfield

QVCDC / QVBAC is an equal opportunity lender, employer and provider. In accordance with Federal law and US Department of Agriculture policy, this institution is prohibited from discrimination on the basis of age, color, disability, family/parental status, national origin, race, religion, sex, gender identity (including expression), sexual orientation, marital status, income derived from public assistance programs, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity funded by USDA.

Please verify that you are human*

AUTHORIZATION FOR CREDIT REPORT