National Credit and Screening Co

National Credit and Screening Co., LLC

DISCLOSURE AND AUTHORIZATION FORM – CONSUMER CREDIT REPORT

(To be completed by Individual and returned to company)

Individual’s Name: ______

FirstMiddleLast

Social Security Number: ______-______-______

Current Address: ______

Street Address

______yrs

CityStateZipcode Length of Residency

Previous Address: ______

Street Address

______yrs

CityStateZipcode Length of Residency

(IF YOU’VE RESIDED AT THIS ADDRESS LESS THAN 2 YEARS, ATTACH A SEPARATE SHEET OF PAPER LISTING ALL PLACES OF RESIDENCE FOR AT LEAST THE PAST FIVE YEARS)

Please provide any other names or social security numbers used in the past, if any:

______

Do you have a Security Freeze on your Trans Union credit report? ___ No ____Yes

If yes, please provide the PIN number: ______

As part of the application process by ______(hereinafter referred to as the “Applicant”) for credit at, and continued evaluation of that credit during the course of the Applicant’s business with Damascus Fuel Company, Inc. (hereinafter referred to as the “Company”), I understand that the Company and/or its agents may conduct an investigation of my personal information, which may include obtaining my credit report. I understand that these records may be used for the eligibility of extending credit to the Applicant. I understand that my consent is required. I authorize the full release of the information described below, without any reservation, during the application process and throughout the Applicant’s doing business with the Company. I also certify that all information provided is correct. Any false statements provided will be considered just cause for termination of credit to the Applicant.

I hereby authorize National Credit and Screening Co., LLC (“NCS”) to obtain my credit report in connection with an application for credit with the Company. I understand that my credit report and the information therein shall be used in compliance with State Law or Federal Law or Fair Credit Report Act or appropriate regulations. I also understand that I have a right to obtain a copy of my own credit report and can dispute any information. I authorize without reservation the full release of these records and for NCS and/or its agents to obtain this information. In addition, I release and discharge NCS, and all of its agents and associates, any expenses, losses, damages, liabilities, or any other charges or complaints for the investigative process.

Upon request, NCS will supply a copy of my report and my rights under the Fair Credit Reporting Act. Requests may be directed to NCS below.

I, ______, hereby authorize, without any reservation, any information company contacted by National Credit and Screening Co., LLC to release the above credit information. A fax or photocopy of this authorization with my signature shall be accepted with the same authority as the original.

Signature: ______Date: ______

For more information:

The Bethpage professional Building; 4250 Hempstead Turnpike, Suite 14, Bethpage, New York 11714-5707

Phone: (516) 605-0671; Fax: (516) 605-0675;

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