INTELLICHOICE, INC. |
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Please print and complete this form to order services. | ||
Potential Employee Information: |
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Print Name:___________________________ | Soc. Sec. #: _________-_______-_______ | |
Date of Birth:__________________________ | Sex __Male __Female | |
Race: __White __Black __Hispanic __Asian | ||
Requester Information |
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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: |
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____ 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. |