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a printer friendly copy. |
| Please
print and complete this form to order services. |
Potential Employee Information:
|
|
| 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) |
|
|
|
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INTELLICHOICE, INC.
P.O. Box 1504
Dawsonville, GA 30534
770-205-1828 (phone)
770-205-8036 (fax) |
| |
