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Company Information
*Company Name:
Branch/Division Name:
*Address:
*City:  *State:   *Zip: 
Contact Information
*Name:  Title: 
*Telephone:  *Fax: 
*E-mail/Username:
 
No. of Employees:
No. of estimated hires next two months:
No. of estimated hires next 12 months:
Type of business:  Yrs in business: 
Website address:
Type of company (check one): Corporation   Partnership   Sole Proprietor
State of incorporation:
Owners and/or Executives of Company
1.  Name:  Title: 
2.  Name:  Title: 
How did you hear about Identi-check, Inc.?
Illinois State Chamber of Commerce   Illinois Manufacturers' Association
Customer Referral   Internet   Sales Call   True Pay  
Financial Information
Credit Application
Identi-check will invoice all customers monthly, via the method checked below. Terms are Net 15 days. The first invoice will include a $30.00 application fee.
Person Responsible For Payment Approval
Name:  Telephone: 
E-Mail:  Fax: 
Accounts Payable Contact
Name:  Telephone: 
E-mail:  Fax: 
Invoice Delivery Method
e-mail   Fax   Mail
By submitting this application, applicant warrants that all information provided by Ident-check, Inc. will be used only for employment screening purposes. Applicant further authorizes Identi-check, Inc. to verify all information provided on this application. All invoices must be paid on time each month, or service will be subject to termination until payment is received.

SUBSCRIBER AGREEMENT

IDENTI-CHECK, INC. agrees to provide a report on each employment candidate as requested by the client. IDENTI-CHECK, INC. will use repositories to gather this information and will supply the data to the client in report form. Please be advised that once the information is furnished to the client, it is no longer in the control of IDENTI-CHECK, and the use of the information becomes the responsibility of the client. Accordingly, by signing below, the client company agrees that it will defend, indemnify and hold IDENTI-CHECK, INC. harmless for any and all legal actions, losses, claims, demands, liabilities, causes of action, costs or expenses imposed upon IDENTI-CHECK, INC. as a result of the use or misuse of any information by the client, its employees, agents or representatives supplied by IDENTI-CHECK, INC.

Understand that if the client is using the services of IDENTI-CHECK on-line, the signed original of the Candidate Agreement MUST be retained at the client’s place of business.

Pre-employment screening services will be billed at the prices outlined in the Price Structure section of the IDENTI-CHECK web site and under the terms stated, unless a special volume agreement is entered into between the client company and IDENTI-CHECK, INC. Although due diligence will be used in obtaining pre-employment screening data, IDENTI-CHECK, INC. must rely on secondary sources and, therefore, charges are for each search undertaken without regard to the content of the report produced.

Please provide authorization to proceed and agreement to the terms and conditions set forth in this letter as indicated by your signature below and return this document to IDENTI-CHECK, INC. by fax at 217-753-3428.

AUTHORIZATION TO PROCEED:
Authorized Representative of Client Company:
Typing your name in the box below, is equivalent to signing the document.
*Signature:    *Printed Name:
*Title:    *Date:    *Company FEIN:
We appreciate payment within 30days.



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