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General Background Check Request

Request Date
Company Name
Address
City
State		Zip
Requested By
Position
Telephone
Fax
EMail

Searches Requested click here for pricing
Workers Compensation Report	Motor Vehicle Report	Credit Report
County Criminal History Report	Federal Criminal Search	Social Security Link
Statewide Criminal History Report	Federal Bankruptcy	Address Update
Civil History Suits and Judgments	Discovery Report

Search #1
Name (Last, First, MI)	Date of Birth (mm/dd/yyyy)
Social Security No	Drivers License No	State
City	County	State

Search #2
Name (Last, First, MI)	Date of Birth (mm/dd/yyyy)
Social Security No	Drivers License No	State
City	County	State

Sub Total	$
Tax (TX residents add 8.25%)	$
Total Amount	$

Method of Payment
Visa MasterCard AmEx Diners Club Exp Date
Credit Card Holder's Name
Billing Address
CASHIERS CHECK, MONEY ORDER, or CREDIT CARD NUMBER *
* If sending a Cashiers Check or Money Order, please allow extra time for processing.

Statewide criminal history searches are not available in all states. If the statewide search is not available in the state I am requesting, please search the country.

I authorize Selection Management to conduct a search of my personal history as indicated above.

Signature	___________________________________	Date ________________

How do you want the results returned to you? Mail EMail Fax

You may click the Submit button, fax the form to 281.419.2502 or mail it to us at the address below. Please enclose a check or money order for the full amount if not paying by credit card.

Selection Management
P.O. Box 130369
The Woodlands, TX 77393-0369 USA
Voice: 281.419.2500, FAX: 281.419.2502