Individual Background Screening Fax Form

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BACK-GROUNDCHEKS.COM

Phone: 1-904-565-1004

Fax Order to: 1-904-565-1652
Mail Orders to:
Screening Department
Back-groundchecks.com
3781-0 South Nova Road
Daytona Beach, Fl 32119

DATE:

1

Ordered by:

^Name:

^{Company (if applicable):}

^Address:

^City: ^State: ^Zip:

^Phone:
^Fax:
^E-mail:

2

Method of Payment:

Visa Discover

MasterCard American Express

Diner's Check

^{Credit Card #:}
^{Exp. Date:}

^{Name On Card:}
^Signature:
^{X___________________________________________}

3

Order:

Qty: Description: Price: Subtotal:

Screening Report

All services rendered by Back-groundchecks.com.
Prices Payable in $US
All orders are shipped via U.S. Mail.
Shipping cost is included in the price of the kit.
No COD deliveries. Grand Total:

Thank You!
http://www.back-groundchecks.com

Office Use Only: This form originated from the www.back-groundchecks.com web site.