CONSENT TO BACKGROUND AND REFERENCES CHECK

I authorize Alain Berthelot to obtain information about me from my credit sources, credits bureaus, current and previous landlords, employers and personal references.

I authorize my credit sources, credits bureaus, current and previous landlords, employers and personal references to disclose to Alain Berthelot such information as Alain Berthelot may request: income and employment history from Federal or State records including State Employment Security Agency records, report from a credit reporting agency, creditworthiness from banks, creditors, employers, existing and previous landlords, and other persons …

NAME:

DOB *

ADDRESS:

PHONE:

DATE:

_____________

SIGNATURE:

* DOB: Date of birth