Your Organization

Company/Organization (required)

Your Name (required)

Title

Email (required)

Phone

States Where You Hire

Approximate Screenings per Year

—Please choose an option—1–2526–100101–250251–500500+

Current Services Used (if known)

Billing Contact

Billing Contact Name

Billing Email

Billing Phone

PO or Vendor Number (if required)

Preferred Payment Method

—Please choose an option—ACH transfer (preferred)Credit or debit card through StripeACH Direct Debit through a Stripe invoiceCheck or other approved arrangementNot sure

Client Portal Status

—Please choose an option—Active and working wellNeed to add usersNeed to remove usersNeed login helpNot currently using the portal

Authorized Portal Users to Add, Change, or Remove
Name, business email, and role (Administrator, Ordering, Report-Only, or Billing). Do not include passwords.

How Can We Help?

Select all that apply

Update company or billing contactsAdd or remove portal usersReview our screening services and pricingSend the updated Employment Screening Service AgreementSend payment instructions or a payment linkOther

Additional Details

Please do not include Social Security numbers, applicant information, bank account numbers, card numbers, or passwords in this form.