SAND MOUNTAIN

ELECTRIC COOPERATIVE

 

 

 

EMERGENCY GENERATOR

FINANCING PROGRAM

CREDIT CHECK RELEASE FORM

 

 

Date_______________________________            This completed form gives Sand Mountain Electric Cooperative permission to conduct a credit and character check on the below named parties:

 

 

 

Name_______________________________________           Spouse____________________________________

 

Social Security Number _______________________              Social Security Number ____________________

 

Drivers License Number_______________________             Drivers License Number____________________

 

Date of Birth ________________________________             Date of Birth _____________________________

 

Place of Employment _________________________               Place of Employment______________________

 

Home Address ______________________________________________________________________________

 

Home Telephone Number _____________________                Daytime Telephone Number________________

 

Do you own your farm? _________________        Are the deeds to the land in your name? _______________

 

 

Signature______________________________________________________________

 

Spouse’s Signature______________________________________________________

 

 

**********************************************************************************************

 

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.  The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Room 1002, 1718 Peachtree Street, NW, Atlanta, Georgia 30367.

 

**********************************************************************************************

 

 

COMPLETE THIS FORM AND RETURN AS SOON AS POSSIBLE TO:

Michele R. Girdauckas

Sand Mountain Electric Cooperative

P.O. Box 277

Rainsville, AL 35986