I understand that a Consumer Report or an Investigative Consumer Report as described above may be obtained. All state motor vehicle bureaus, law enforcement agencies and courts are authorized to release all written and verbal information about me. I hereby release all individuals, companies, corporations, and agencies, public or private, connected therewith from any and all liability associated with the dissemination of such information pertaining to me. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent that such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

APPLICANT'S PRINTED NAME _________________________________________

SOCIAL SECURITY NUMBER ____________-____________-___________

DATE-OF-BIRTH ________-________-________

DRIVER'S LICENSE # ________________________________ STATE: ___________

CURRENT ADDRESS ___________________________________________________

CITY ___________________________ STATE _________ ZIP _________________

APPLICANT'S SIGNATURE _______________________________________________

DATE SIGNED ________-________-________

Signature: __________________________________

Print this form and fax to the number 1-714-276-6589

Fax Order Form

FAX this completed form to 1-714-276-6589

Please print clearly to avoid a delay in processing. Your personal information

is kept strictly confidential and is not shared with third parties. Privacy Policy

Subject Information

First Name: ______________________ Last Name:______________________

Driver License Number: __________________________________ State: _____

CIRCLE A DELIVERY METHOD: (Only one delivery method is permitted.)

1) EMAIL - Please allow 3-5 business days to receive your record abstract.

2) FAX - Please allow 3-5 business days to receive your record abstract.

Your Billing Information

First Name: ______________________ Last Name:______________________

Address: _________________________________________________________

City: ________________________ State: _______ Zip Code: ______________

Phone: ________________________ Fax: _____________________________

Email Address:____________________________________________________

Your Credit Card Information (Visa or MasterCard Only)

We DO NOT ACCEPT American Express or Discover Card.

Account Number: ___________ - ____________ - ___________ - ___________

Expiration Date: _________ / ________ (mm/yy)

Last three number(back of your card) ____________

Service Agreement

I agree to abide by all applicable local, state and federal laws with regard to the report(s) I am ordering

today and will not share this information with any third parties or display it a publicly. Under penalty of

perjury, I swear that I am the authorized cardholder of the credit card indicated above and grant

permission to have it charged for the total amount of __________+Tax

PLEASE VERIFY ALL OF THE INFORMATION PROVIDED ABOVE, ESPECIALLY THE DRIVER LICENSE NUMBER. FAILURE TO PROVIDE A CORRECT DL # WILL RESULT IN NO RECORD AND YOUR CREDIT CARD WILL STILL BE CHARGED.

ALL ORDERS ARE DISPATCHED TO THEIR RESPECTIVE STATE DMV

RESEARCHERS IMMEDIATELY. NO CANCELLATIONS OR CHANGES CAN BE MADE AFTER YOU FAX YOUR ORDER.

Signature: __________________________________ Date:______________

Print Name: __________________________________