All information must be completed to conduct the criminal history search.

Applicant's First Name

Applicant's Gender (M for Male or F for Female)

Applicant's Middle Name, if any

Applicant's Last Name

Applicant's Maiden Name

Applicant's Social Security Number

Applicant's Date of Birth (mmddyyyy)

Applicant's Street Address:

City

State

ZIP Code:

Applicant's/Employee's/Subject's Email Address:

Applicant's/Employee's/Subject's Phone Number, including area code:

National Criminal History Search Yes  

I have signed and sent to SecurTest the "SecurTest Employment Subscriber Application and Service Agreement" agreeing to the terms and conditions set forth therein. I certify that the subject of this request is an applicant for employment or an existing employee and that as the employer we are responsible for following the Fair Credit Reporting Act and other applicable laws.
Requests for applicant or existing employees ONLY. Yes

I certify that the applicant or employee has signed a SecurTest approved authorization. I further certify that if adverse criminal history information is reported by SecurTest that I will give the applicant SecurHomeland^Verify to authenticate the criminal history within 3 business days. I agree to fax or mail a copy of the SecurTest authorization today, marking the form SUBMITTED ONLINE in the upper right corner. I understand that SecurTest may require the form to be faxed sooner to (815) 550-8821. You can also scan and upload the authorization. We MUST have the authorization before conducting the background search. Yes

You may upload a File along with your submission: