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Potential Employee Information:
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Name:___________________________ |
Soc. Sec.
#: _________-_______-_______ |
Date of
Birth:__________________________ |
Sex
__Male __Female |
Race:
__White __Black __Hispanic __Asian |
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Requester Information
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Name:___________________________ |
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Current
Address:_______________________ |
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____________________________________ |
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City:________________________________ |
State:______ |
Zip:___________-_______ |
Phone Number:(____)
______-____________ |
Fax
Number:(____) ______-____________ |
E-mail:______________________________ |
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Visa:____
MasterCard:____ |
Card
Number:_________________________ |
Expiration
Date:_____/_____/_____ |
Name as it
appears on Card:___________________________________________ |
Please Select Report Types:
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____ Social Security
Number Verification |
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____ Criminal History
(County) |
____
Criminal History (Statewide) |
List Counties:
_______________________________ |
List
States:_________________________________ |
____ Motor
Vehicle History |
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List
States:_________________________________ |
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____ National Wants
And Warrants |
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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)
678-317-0940 (fax) |
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