RELEASE AUTHORIZATION 
 
Please check ONE of these boxes: 
 
I am an Entity.  
 
/ 
 
 
(Print Name of Entity) 
 
EIN 
 
I am an Individual.   
/ 
 
 
(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 reviewing applications for 
loans administered through the Economic Development Bank. 
 
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until such time as withdrawn in writing.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 
Current Physical Address (including City, State, Zip Code) 
 
 
ACKNOWLEDGMENT 
 
STATE OF   
 
COUNTY OR DISTRICT OF   
 
) 
) SS: 
) 
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. 08/2020)