Application and contract for service-GVT Agency Template

Application and contract for service—Governmental agency. In compliance with Public Law 91-508 The undersigned (hereinafter referred to as the Applicant) being duly authorized by _________(Official Name of Agency or Department), petitions the Credit Bureau named below (hereinafter referred to as the Credit Bureau) for the use of its services upon the basis outlined below, and if accepted by said Credit Bureau as a non-member user of service, agrees that the following shall constitute the service contract between the Applicant and the Credit Bureau. THE APPLICANT CERTIFIES AND AGREES: 1. That all information or reports will be requested only for the exclusive use of the Applicant and solely in connection with the exercise of official duties. 2. That at the time a request for information or credit report is made of the Credit Bureau, the Applicant's representative authorized to make such request will certify as set forth below the purpose of the report, which shall be only when the Applicant intends to use the information for a permissible purpose, namely: A In connection with a credit transaction involving the consumer on whom the information is to be furnished and involving the extension of credit to, or review or collection of an account of, the consumer; or B For employment purposes; and Applicant agrees (1) to give advance notice to the consumer that a report may be requested, for employment purposes; and (2) to identify to the Credit Bureau each request for a report to be so used at the time such report is requested; or C In connection with the underwriting of insurance involving the consumer; or D In connection with a determination of the consumer's eligibility for a license or other benefit granted by a governmental instrumentality required by law to consider an applicant's financial responsibility or status; or E In connection with a business transaction involving the consumer; and the Applicant agrees to identify to the Credit Bureau each request at the time such report is ordered, and to certify the legitimate business need for such report. 3. Unless the request for information or credit report is for a purpose stated in "2" above, the Credit Bureau shall furnish identifying information only respecting the consumer, limited to his name, address, former addresses, place of employment, or former places of employment. 4. To pay for all information or reports which the Applicant shall request the Credit Bureau to furnish, according to the schedule of charges now or subsequently established by the Credit Bureau for services to governmental agencies. 5. To comply with all the provisions of Public Law 91-508, which provides that any person who knowingly and willfully obtains information on a consumer from a consumer reporting agency under false pretenses shall be fined not more than $5,000 or imprisoned not more than one year, or both. THE CREDIT BUREAU AGREES: 1. To maintain files on individuals, firms or corporations, recording information furnished by its members or subscribers or obtained from other available sources. 2. To furnish all appropriate information under the terms of this application (and specifically under the terms set out in Applicant's representation number "2" above) including but not limited to: identifying information, credit history, employment and public record information in file; such information being furnished at the special request of the Applicant, as evidenced by the signature of this contract. IT IS MUTUALLY AGREED that this service contract, if accepted by the Credit Bureau, shall remain in force and effect until written notice of cancellation shall be given by either party. It is further agreed, however, that if Applicant is delinquent in the payment of charges or is guilty of violating the terms of this contract, the Credit Bureau may, at its election, discontinue all further services and cancel this contract immediately by written notice to the Applicant. The Applicant will indicate on a separate inquiry form provided by the Credit Bureau for this specific purpose, the identification of each person, firm or corporation on whom any report or information is requested under the terms and conditions of this contract, including a positive certification of the purpose for which the information is being sought and for which it will be used. Dated at _________, this day _________[date] Applicant _________(Full Official Name of Dept. or Agency) By _________ Title _________ Address _________ Telephone _________ Zip Code _________ Persons to be Authorized to Request Reports _________ Accepted for the Credit Bureau Named Below By _________ Title _________ Date _________ Code Number Assigned _________