InfoMax requires that all the information below be provided when requesting a credit report. Should the request be for a joint report, each consumer must complete and sign the form and fax it to InfoMax at 1-877-994-0370. Mail the original to InfoMax, Inc., P.O. Box 15744, Rio Rancho, NM 87174.

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip:

Social Security Number:

Date of Birth: _____/______/_______

ALL CONSUMER CREDIT REPORTS REQUIRE THE CONSUMER'S AUTHORIZATION

I authorize InfoMax, Inc. to obtain a consumer credit report on myself.

Print Name:_____________________________________

Signature:_______________________________________