Application For Services

Basic Company Information

Full Legal Name of the Company:

This field is required.

NAICS Number:

Are there additional companies/legal entities that will be using GHRR services under this contract?

Yes

Industry:

If “Yes” please provide the names of the other companies. You may attach a separate document if more space is needed.

Are any of these companies based outside of the United States? If yes, please provide the name and location for each applicable company.

Street Address:

City:

State:

ZIP:

Account Primary Contact First Name:

Account Primary Contact Last Name:

Title:

Email:

Phone:

Company Website:

Phone Number:

Federal Tax ID No.:

State of Incorporation/Organization:

Number of Years in Business:

Number of Employees:

Anticipated Number of Screens Per Year:

Please enter a number greater than 0.

Are you a staffing company or other type of business that provides employment or labor services?

Yes

Does your company use a third-party agent/company to manage HR administrative functions, such as background screening?

Yes

Purpose for Requesting Background Screening:

If “Other” is selected, please provide more information as to purpose:

Include Drug Testing Services