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I would like to place a security freeze on my credit report.
 
____________________________________________________________________
First name                    Middle                  Last name                         Suffix (Jr., III, etc.)
 
Previous name or maiden name (if applicable):
 
____________________________________________________________________
 
Current full address including zip code:
 
____________________________________________________________________
 
____________________________________________________________________
 
Former addresses for the last 5 years:
 
1)__________________________________________________________________
 
2)__________________________________________________________________
 
Date of Birth _____________________________
 
SSN# __________________________________
 
Drivers' License - State and Number ______________________________________
 
Include one piece of ID to verify your address:
(A copy of driver's license, government issued ID, water bill, electric bill, etc.)
 
Method of payment*  (Contact the company for details)
 
Personal check enclosed _________   Money order enclosed _________
 
Credit card # ______________________ Type of card: _______________________
								   (Visa, MasterCard, Discover)
 
Name on card ________________________________________________________
 
Expiration date _____________________
 
Card ID (three-digit security number on back of card) _________
 
*IF CLAIMING ID THEFT AND A FREE FREEZE, INCLUDE INFORMATION
SUCH AS ID THEFT AFFIDAVIT, POLICE REPORT, DMV REPORT, ETC.)
 
SIGNATURE:
 
______________________________________ Today's date ___________________
 
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