Application and contract for single report. The undersigned (hereinafter referred to as the Applicant) 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. Request is hereby made to furnish the Applicant a credit report on the following: Name _________ Address _________ The Applicant certifies that the purpose of this report is: _________ and that said purpose is in compliance with Public Law 91-508 ยง604 (Fair Credit Reporting Act.) THE APPLICANT FURTHER AGREES: That if the report is to be used for employment purposes, (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 used at the time such report is requested; or To adhere to all provisions of Public Law 91-508 (Fair Credit Reporting Act) and other applicable state and federal statutes. Willful failure to comply is punishable under the FCRA and 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 1 year, or both. That information is being requested only for the Applicant's exclusive use. All information received from the Credit Bureau, whether written, printed or oral, same being for exclusive use of Applicant, and in case the disclosure of such information leads to any claims or litigation, to hold the Credit Bureau harmless from any liability or damages resulting therefrom. The Credit Bureau shall not be liable in any manner whatsoever for any loss or injury to Applicant resulting from the obtaining or furnishing of such information and shall not be deemed to have guaranteed the accuracy of such information, such information being based, however, upon reports obtained from sources considered by the Credit Bureau to be reliable. To pay upon receipt of billing for the report which the Applicant hereby requests the Credit Bureau to furnish, according to the regular Non-Member rate schedule of charges established by the Credit Bureau, plus the charges for any special telephone or telegraph services or other special services rendered. THE CREDIT BUREAU AGREES: To furnish all available pertinent information on the subject of this inquiry, 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 Applicant, as evidenced by the signature of this application. Dated at _________, this day _________[date]
Applicant _________
By _________
Title _________(Owner, Corporate Officer, Partner, or Manager) Address _________ Type of Business _________ Bank References _________ Trade References _________ Zip Code _________ Telephone _________
Accepted by the Credit Bureau named below _________ By _________ Title _________ Date _________