Please complete this form, execute the Subscriber Agreement and submit to us
* Required

Company Information
Company Name:	*
Branch/Division Name:	*
Address:	*
City:	*  State: *  Zip: *
Contact Information
Name:	*  Title: *
Telephone:	*  Fax: *
E-mail:	*
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*
	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.
We appreciate payment within 30days.