INTELLICHOICE, INC.
Order by Fax
Please print and complete this form to order services.

Potential Employee Information:

 Please fill out the RELEASE FORM.
Print Name:___________________________ Soc. Sec. #: _________-_______-_______
Date of Birth:__________________________ Sex __Male  __Female
Race:  __White  __Black  __Hispanic  __Asian  

Requester Information

  
Print Name:___________________________ Please   Fax   Mail  my report (circle choice).
Current Address:_______________________  
____________________________________  
City:________________________________ State:______ Zip:___________-_______
Phone Number:(____) ______-____________ Fax Number:(____) ______-____________
E-mail:______________________________  
Visa:____  MasterCard:____ 
Card Number:_________________________ Expiration Date:_____/_____/_____
Name as it appears on Card:___________________________________________

Please Select Report Types:
____ Social Security Number Verification  
Not all states offer all reports, please see Pricing Information for a complete list.
   
____ Criminal History (County) ____ Criminal History (Statewide)
List Counties: _______________________________ List States:_________________________________
____ Motor Vehicle History  
List States:_________________________________  
____ National Wants And Warrants ____ National Sex Offender
____ Criminal History (County) ____ Criminal History (Statewide)
   

INTELLICHOICE, INC.
 P.O. Box 1504 Dawsonville, GA 30534
770-205-1828 (phone) 770-205-8036 (fax)