BUSINESS NAME:	FED. ID #:
OWNER NAME(S):	SSN:
SSN:
ADDRESS:
PHONE #:	FAX #:
EMAIL:
I authorize the Virginia Department of Forestry to contact the three (3) businesses listed below, one of which must be a bank, to obtain credit references. I also authorize the Virginia Department of Forestry to obtain a credit report, if needed. This information will be used in determining credit approval for the purchase of tree seedlings. I request that the Virginia Department of Forestry keep the credit references confidential.
1.
Accredited Banking Institution	Account #
Address	City	State	Zip
Contact Person	Phone #
2.
Business	Account #
Address	City	State	Zip
Contact Person	Phone #
3.
Business	Account #
Address	City	State	Zip
Contact Person	Phone #
Owner Name	Owner Signature	Date
Information received will be treated with strict confidentiality. Please return with credit application to: Virginia Department of Forestry, Attn: Fiscal Division, 900 Natural Resources Drive, Suite 800, Charlottesville, VA 22903 Phone: (434) 220-9058; Fax: (434) 220-9155