Customer Online Application Form

Customer Application Online Form

Customer Application

Alpha Background Investigations

Date

Important: All information must be completed in its entirety. Please print clearly and legibly to help ensure accurate and timely processing.

General Company Information

Company Name

Years and Months in Business

Type of Business

Corporation

Partnership

Sole Owner

Non Profit

Have you previously applied to purchase reports from ABI?

Yes

If yes, under what business name and when?

Physical Street Address (No P.O. Box numbers please):

Address Line 1

Address Line 2

City

State

Zip Code

Country

Contact Name (First Name)

Last Name

Phone Number

Fax Number

How long at present address, years and months?

Previous Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

How long at previous address, years and months?

Do you own or Lease the building in which you are located (please check one)

Own

Lease

Type of business (Products or services provided)

Do you have an Investigation License? If yes, please provide a copy with this application.

Yes

Approximately how many Pre-Employment Profiles will you be ordering monthly?

Affiliated or Parent Company Information

Do you use credit profiles or Pre-Employment Profiles for more than one business or branch of your organization?

Yes

Affiliated or Parent Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Federal ID Number

Permissible Purpose Information

(Application will not be processed unless this information is provided)

Describe the specific purpose for which Experian credit information will be used. Please check one or more:

Employment Background Screening

Tenant Screening

Extension of Credit

Not running Credit Reports

FCRA Requirements

I have read and understand the “FCRA Requirements” and “Access Security Requirements” notice and will take all reasonable measures to enforce them within my facility. I certify that I will use the Experian/Trans Union credit report for no other purpose than what is stated in the Permissible Purpose section on this application. I will not sell the report to any 3rd Party directly or indirectly. . All replications of this Application shall be deemed an original. I certify that I have read the above statements and all information provided is accurate and hereby authorize the bank reference to release information to Alpha Background Investigations, LLC I authorize Alpha Background Investigations, LLC to charge my Credit Card for services rendered if they are not paid within 30 days or other agreed terms and conditions.

Full Name

Title

END USER CERTIFICATION OF USE

Company Name

END USER CERTIFICATION OF USE FOR EMPLOYMENT INSIGHT REPORTS

In compliance with the Federal Fair Credit Reporting Act as amended by the Consumer Credit Reporting Reform Act of 1996 (the “Act”), Company Name(“End User”) hereby certifies to Consumer Reporting Agency that it will comply with the following provisions: 1. End User will ensure that prior to procurement or causing the procurement of a consumer report for employment purposes (an Employment Insight Report): a) a clear and conspicuous disclosure has been made in writing to the consumer at any time before the report is procured or caused to be procured, in a document that consists solely of the disclosure, that a consumer report may be obtained for employment purposes; and b) the consumer has authorized in writing the procurement of the report by the End User. 2. In using a consumer report for employment purposes, before taking any adverse action based in whole or in part on the report, the End User shall provide to the consumer to whom the report relates: a) a copy of the report; and b) a description in writing of the rights of the consumer under the Act, a copy of which is attached hereto (“Summary of Consumer Rights”). The information from the consumer report will not be used in violation of any applicable federal or state equal employment opportunity law or regulation. End User hereby acknowledges receipt of the Summary of Consumer Rights.

Name

Title

EXHIBIT A

TERMS AND CONDITIONS TALX EMPLOYMENT INFORMATION 1. Any information services and data originating from TALX will be requested only for subscriber’s exclusive use and held in strict confidence except to the extent that disclosure to others is required or permitted by law. Only designated representatives of subscribers will request TALX Employment Information on Subscriber’s employees, and employees will be forbidden to obtain TALX Employment Information on themselves associates or any other persons except in the exercise of their official duties. Subsriber will not disclose TALX Employment information except as permitted or required by law, but will refer the subject to TALX. 2. Subscriber will hold TALX and all its agents harmless on account of any expense or damage arising or resulting from the publishing or other disclosure of TALX Employment Information by subscriber its employees or agents contrary to the conditions of Section 1 above or applicable by law. 3. Subscriber recognizes that TALX does not guaranteed the accuracy or completeness of TALX Employment Information and Subsriber releases TALX and Tax’s agents, employees, affiliates, credit reporting agencies and Independent contractors from an liability including negligence in connection with the provision of TALX Employment Information and from an loss or expense suffered by Subscriber resulting directly or Indirectly from TALX Employment information. Subscriber covenants not to sue or maintain any claim, cause of action, demand, cross-action counterclaim, third-party action or other form of pleading against TALX, TALX’s agents, employees, affiliated credit reporting agencies, or Independent contractors arising out of or relating in any way to the accuracy, valididity, or completeness of any TALX Employment Information. 4. Subscriber will be charged for the TALX Employment Information by CRA which is responsible for paying TALX for the TALX Employment Information; provided, however, should the underlying relationship between Subscriber and FRA Terminate at any time during the term of this agreement charges for the TALX Employment Information will e Invoices to Subscriber and Subscriber will be solely responsible to pay TALX directly. 5. FAIR CREDIT REPORTING ACT CERTIFICATION: A COPY OF THE FAIR CREDIT REPORTING ACT IS ON THE WEBSITE FOR ALPHA BACKGROUND INVESTIGATIONS. End User hereby acknowledges the above compliance in regards to TALX EQUIFAX COMPLIANCE

Name

Title

Authorized Signature

I agree that all of the information provided is true and that I am authorized by the organization to provide and agree to the conditions provided.

Authorized Name

Official Signature (Please check below for official authorization)

Authorized Signature

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