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REQUEST FOR CREDIT REFERENCE

Current Date: Current Date

For the benefit of:

Company Name

City, State Zip or Postal Code

Phone Number

Company Name has requested credit with our company and has named you as a reference for credit. Company Name has authorized us to conduct a reference check and contact you on their behalf for the following information. I hereby authorize the institution listed in this credit reference request to release necessary information to the company for which credit is being applied for in order to verify the information contained herein.

Signature Date

Credit Reference Details

Please provide us with the following information:

How long has the above-named company had an account with you or your company? What is the highest balance the above-named company has reached? Average balance? Has the above-named company had any late payments or overdrafts?

Have you had a satisfactory relationship with the above-named company? Does the above-named company have an outstanding balance with you or your company? Note - "outstanding balance" for the purpose of this credit reference refers to a balance which is past due or in which interest only payments are being made. If you have any additional information that would help us to evaluate the above-named company, please attach it to this credit reference.

All information provided to us is held in the strictest confidence and is not provided to the party or parties requesting credit.