*Screening Selection: |
Basic Background Screen = $49.95
Standard Background Screen = $99
Advanced Background Screen = $249 and includes drug and urine check
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| Select an Employer from the drop down box below. |
*New Employer / Prospective Employer:
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OR
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| NOTE: If your company is not listed above and you selected Other, please select one of the following delivery methods and input below: |
*Delivery Methods: |
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*First Name: |
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*Middle Name: |
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*Last Name: |
If married female, please list maiden name only. |
*E-mail: |
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*Date of Birth: |
In the following format: mm/dd/yyyy |
*Driver's License Number: |
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*Last 4 digits of Social Security Number: |
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*Current Address: |
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*Current City, State, Zip: |
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| If you have not lived in your current address for at least 5 years, please list the last three years of residences: |
Address 1: |
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City, State, Zip: |
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Address 2: |
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City, State, Zip: |
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Address 3: |
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City, State, Zip: |
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*Have you ever been convicted of a crime?: |
Yes
No
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*If yes, please explain: |
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| Please list three references with phone numbers: |
*Current Employer Name: |
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*Current Employer Phone: |
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| (Your employer will not be contacted) |
*Personal Reference 1: |
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*Reference 1 Phone: |
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*Personal Reference 2: |
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*Reference 2 Phone: |
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| Credit Card Information: |
*Credit Card Type: |
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*Credit Card Number: |
- - - |
*Card Expiration: |
/
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*Card CID/CIV #: |
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*Authorization: |
Yes, I authorize the verification of records to the following: Department of public safety, driving record search, National criminal records, federal criminal records, sex offender registry, prison inmate search, arrest warrant search, civil records search, employment verification and workers compensation claim history. |
*Agreement: |
Yes, I understand that this background screen is non refundable and non rescindable, all sales are final. The completed background check will be sent to your perspective employer within 7 days |
Comments |
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