[Please Click Here To Print Form]

[ Please Print Information Legibly ]

BRT Financial, Inc.

Borrower’s Certification & Authorization To Release Credit

The undersigned hereby authorize the release of all credit information, including loans, leases, checking and savings accounts, trade references and personal credit history pertaining to its company, its principles, and the name(s) of person(s) authorizing this credit release.

This Authorization allows BRT Financial, Inc. and/or its designees or assignees to pull credit on person(s) signing below and authorizes the release to BRT Financial, Inc. of all credit history and information required by BRT Financial, Inc. for the purpose of processing and evaluating applicant's credit transaction.

Applicant also permits BRT to release his or her credit information and otherwise exchange information regarding applicant's credit transaction to various business professionals involved in applicant's portion of the lending transaction. Such authorization shall extend to subsequent updates for credit history.

A Facsimile of this Authorization shall constitute a Legal and Binding Copy.

Principle First, Middle, Last Name:

Age:                   DOB:                                                           Home Phone:

SS No:                                                                Years at Present Address:

Current Home Address:

Last Address if less than 2 Years at Present Address:

Principle Signature:

Date Signed:

Fax To: 904-513-9229

(Your Credit Card Statement Will Show A Charge From BRTFINANCIA@PayPal)

[Please Click Here To Print Form]

BRT Financial, Inc.
445 State Road 13N Suite 26-308
Jacksonville, FL
Phone: 904. 551. 6090
Fax: 904. 513. 9229