Authorization For Ssa To Release Ssn Verification

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Form Approved
Social Security Administration
OMB No. 0960-0760
Authorization for the Social Security Administration (SSA) To Release Social
Security Number (SSN) Verification
Printed Name:
Date of Birth:
Social Security Number:
I want this information released because I am conducting the following business transaction:
Seeking appointment to FINRA Neutral Roster
Reason (s) for using CBSV: (Please select all that apply)
Mortgage Service
Banking Service
Background Check
License Requirement
Credit Check
with the following company ("the Company"):
Company Name: P r e - Emp l oyme n t ,
I n c .
Company Address: 8700 Cr ownh i l l
B l vd #703 , Sa n An t on i o , TX 78209
I authorize the Social Security Administration to verify my name and SSN to the Company and/or the
Company's Agent, if applicable, for the purpose I identified.
The name and address of the Company's Agent is:
Compu t e r I n f o rma ti on De v e l opme n t LLC
713 W. Du a r t e Rd #106 , Ar ca d i a , CA 91007
I am the individual to whom the Social Security number was issued or the parent or legal guardian of
a minor, or the legal guardian of a legally incompetent adult. I declare and affirm under the penalty of
perjury that the information contained herein is true and correct. I acknowledge that if I make any
representation that I know is false to obtain information from Social Security records, I could be found
guilty of a misdemeanor and fined up to $5,000.
This consent is valid only for 90 days from the date signed, unless indicated otherwise by the
individual named above. If you wish to change this timeframe, fill in the following:
This consent is valid for
days from the date signed.
(Please initial.)
Date Signed
Relationship (if not the individual to whom the SSN was issued):
Contact information of individual signing authorization:
Phone Number
Form SSA-89 (06-2013)


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