RELEASE AUTHORIZATION 
 
Please select ONE of the following options: 
I am an Entity.   
/ 
 
 
(Print Name of Entity) 
 
EIN 
 I am an Individual holding five percent (5%) or more ownership interest in the entity. 
 
 
/ 
  
(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 processing applications for tax incentives administered through the Virgin Islands Economic Development 
Authority. 
 
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effect until such time as withdrawn in writing.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 Address 
 
 
Current Physical Address (including City, State, Zip Code) 
 
 
ACKNOWLEDGMENT 
STATE OF __________________________ ) 
 
 
 
 
 
 
 
 
 
 
 
              
)  SS: 
COUNTY OR DISTRICT OF______________ )                                                                           
 
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. 06/2024) 
SIGN