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Registration Form for Background Check 21

$29.00 Background Check!

No Registration Fees! No Required Minimum Orders!

Unless Custom Integration is Required, No Set-Up Fees!¹

We are a client-focused company, which means you can count on real-time customer service every step of the way. Do not hesitate to call 800-445-8001 or email info@securtest.com if you have any questions!

¹Set-up fees may only apply if you require custom integration to your HRIS or similar system.

Organization Name:*

Primary Contact Name (Main Account User):*

Title:*

E-mail:*

Accounts Payable Email

example@example.com

Phone Number:*

Area CodePhone Number

Cell Phone Number:

Area CodePhone Number

Fax Number:

Area CodePhone Number

Organization Website

Corporate Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Is your billing address different than the mailing address above?*

YesNo

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Billing Contact Person (CFO, Manager, etc.)*

First NameLast Name

Billing Contact Email*

example@example.com

You must notifiy SecurTest of any changes to authorized persons, emails, or points of contacts for billing.

How many employees, contractors, or subcontractors do you have?

Approximately how many background checks do you anticipate ordering per year?

How many hiring centers / locations do you have?

Is there an additional authorized user who would require secure access to Order and/or View Background Reports? (Recommended)*

YesNo

Name of the Additional User:

E-mail of the Additional User:

Phone Number of the Additional User:

Does the additional authorized user above need access to Order Reports, View Reports, or both?

Order ReportsView ReportsOrder and View Reports

Is there an additional authorized user who would require secure access to Order and/or View Background Reports?*

YesNo

Name of the Additional User:

E-mail of the Additional User:

Phone Number of the Additional User:

Does the additional authorized user above need access to Order Reports, View Reports, or both?

Order ReportsView ReportsOrder and View Reports

Your organization may have as many authorized users as needed at no extra charge. To request additional authorized login users/accounts, please contact SecurTest, Inc. at info@securtest.com or call us at (800) 445-8001.

Pricing Addendum

The price per Background Check 21 is $29.00 per candidate.

Please print this page, as it is an addendum to the Professional Service Agreement.

Click Next will take you to the agreement.