Background Check Request Form
Request Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose of the Background Check
Position specific
Job requirement
Supervisor of Minor
Teaching Minors
Employee's Name
First Name
Last Name
Gender
Male
Female
Department
Job position/title
Requester's Name
First Name
Last Name
Requester's Email
example@example.com
Requester's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Payment Information
Select service or services below
prev
next
( X )
Background Check
$10.00
$
10.00
Â
Â
Criminal Background Check
$10.00
$
10.00
Â
Â
Credit Background Check
$10.00
$
10.00
Â
Â
Motor Vehicle Record Background Check
$10.00
$
10.00
Â
Â
Payment Method
Cash
Credit Card
Check
Wire Transfer
Bank Transfer
PayPal
Other
Do you want to send the background check to a recipient?
Yes
No
Name of the Receiver
First Name
Last Name
Email of the Receiver
example@example.com
Phone Number of the receiver
Please enter a valid phone number.
Format: (000) 000-0000.
Address of the receiver
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Request
Should be Empty: