CCR Basic Plus Report Only

ALERT!

If you have placed a security freeze on your credit history for any reason, you must contact the credit bureau and have the freeze temporarily "lifted" so a credit report may be obtained by Capitol City. Once you have had the freeze lifted, you may complete this order form.

I did not freeze my credit history.*

I would like to continue ordering.

Be sure to complete the entire Order Form, provide your credit card information, and your electronic signature in the designated areas on this form.

Number of Applicants*

Single ApplicantCo-Applicant

Realtor or Landlord Requesting This Report*

First NameLast Name

Realtor/Landlord E-mail*

Realtor/Landlord Phone Number*

Area CodePhone Number

Full Name*

First NameMiddle NameLast Name

SSN*

Social Security Number

Date Of Birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState

Zip Code

E-mail*

Phone Number*

Area CodePhone Number

Co-Applicant: Full Name

First NameMiddle NameLast Name

Co-Applicant: SSN

Social Security Number

Co-Applicant Date Of Birth

MonthDayYear

Co-Applicant: Address

Street Address

Street Address Line 2

CityState

Zip Code

Co-Applicant: E-mail

Co-Applicant: Phone Number

Area CodePhone Number

The Applicant consents to the collection, use and disclosure of the Applicant’s personal information by the Landlord and/or agent of the Landlord, from time to time, for the purpose of determining the creditworthiness of the Applicant for the leasing, selling or financing of the premises or the real property, or making such other use of the personal information as the Landlord and/or agent of the Landlord deems appropriate.By submitting this form, The Applicant represents that all statements made above are true and correct. The Applicant is hereby notified that a consumer report containing credit and/or personal information may be referred to in connection with this rental. The Applicant authorizes the verification of the information contained in this application and information obtained from personal references. This application is not a Rental or Lease Agreement. In the event that this application is not accepted, any deposit submitted by the Applicant shall be returned.

Please read the Terms of Use of service, as displayed below, and save/or print a copy for your records.

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I AUTHORIZE CAPITOL CITY CREDIT CO, LLC, TO OBTAIN CREDIT INFORMATION PERTAINING TO MYSELF. THIS MAY INCLUDE CREDIT HISTORY, EMPLOYMENT, CRIMINAL, EVICTION, AND RENT PAYMENT VERIFICATION.

Single Applicant - Signature*

I AUTHORIZE CAPITOL CITY CREDIT CO, LLC, TO OBTAIN CREDIT INFORMATION PERTAINING TO MYSELF. THIS MAY INCLUDE CREDIT HISTORY, EMPLOYMENT, CRIMINAL, EVICTION, AND RENT PAYMENT VERIFICATION.

Co-Applicant - Signature

Type of Credit Card*

Master CardVisaBill Landlord/Agent

*To select this option you must have been instructed by your Landlord/Agent to check the "Bill Landlord/Agent" box on this order form and been given their code.

Select Report*

Basic Plus Report Only - Single$23.50

Basic Plus Report Only - Co-Applicant$36.98

Enter coupon

Subtotal $0.00Tax $0.00Total $0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Basic Plus Report Only

Single Applicant Information

Co-Applicant Information

Credit Card