University of Colorado at Boulder

							                       University of Colorado at Boulder

         CREDIT AUTHORIZATION INFORMATION

             For an Individual                           For a Business/Organization

         CUSTOMER INFORMATION
                                                  Customer Name _______________________
Customer Name _______________________
                                                  Federal Employee ID # ____-_____________
Current Home Address
        _______________________________
        _______________________________           Dept. Contact Person ___________________
        _______________________________

Phone (______) _____ - ________                   Address
                                                         _______________________________
Customer Permanent Address                               _______________________________
      _______________________________                    _______________________________
      _______________________________                    _______________________________
      _______________________________

Date of Birth ________ / ________ / ________      Phone (______) _____ - ________
SSN ________________________________
                                                  Other Credit References - Banks, Attorneys,
Driver’s License State ______ # ___________       Businesses, Dun & Bradstreet Listings, Etc.
Name of Nearest Relative or Guardian Not Living            _______________________________
with Debtor ____________________________                   _______________________________
                                                           _______________________________
Address of Same                                            _______________________________
       _______________________________                     _______________________________
       _______________________________                     _______________________________
       _______________________________
                                                  _____________________________________
Other Credit References (Banks, Retail Stores,
Credit Card type & issuer [but not number])       Prepared By     _______________________
        _______________________________
        _______________________________           Extension       ________________________

         EMPLOYER INFORMATION                     Campus Box      ________________________

Current Employer and Address                      Date            ________________________
       _______________________________
       _______________________________            _____________________________________
       _______________________________
       _______________________________
                                                  Credit Approved By ____________________
Phone (______) _____ - ________ ext. _____