I certify that I have read the above and my permissible use for this credit report applies
to  this number above:  1  2  3  4  5  6  7  8  9  10  11
If this form (PDF Form) is received at US UNCOVER with no permissible use checked, it cannot be processed!

Person's Last Name:  First:   Mid In:
                       Address:
                                 City:  State:  Zip Code:   
                        Social Security# (SSN): Date of Birth (DOB):       

Name of person requesting report: Date:
      Company (or enter 'NONE'):    Your position:

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Send report by:  
Fax:    E-Mail:    or to Address: add $2.95 P&H

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NOTICE: due to changes in the law, we can only process credit reports with the subject's permission. Therefore
you must print this form and fax it to:  1 888-867-4202
or you may print this form and mail with check to:  
U.S. UNCOVER  3288 Wolfson Dr.  #2A, Baldwin, NY 11510

Comments: 

I hereby give my consent and permission to  U. S. UNCOVER to access my credit  history  records.  Furthermore, I waive my position of privacy and promise to hold U.S. UNCOVER, it's agents and affiliates harmless for any damage which may occur from the disclosure of such records and information.

Signature of subject::