CLIENT INFORMATION

Name:

Company: Title:

Address:

City: State: Zip Code:

Phone Number: Ext.: Fax Number:

*E-mail Address: (*Email Required)

APPLICANT'S INFORMATION

Last Name: First Name:

Alias/Nickname:

Address:

City: State: Zip Code:

DOB: Social Security Number:

TYPE OF INQUIRY

Type of Investigation: Statewide Criminal County Criminal Credit OIG

Specify State of County:

ADDITIONAL INFORMATION/SPECIFIC INSTRUCTIONS/OBJECTIVES FOR INVESTIGATION:

(Your email address is required in order to submit this form)

By submitting this form user certifies that all
applicable applicant releases have been secured and are on file.