This Agreement (the “Agreement”) is entered into by and between SecureSearch (, its applicable subsidiaries and affiliated companies, and the undersigned (“Customer”). Affiliate shall mean any business entity that controls, is controlled by or is under common control with a party.

This agreement for service is made and entered into on the date of

,Please enter the date by and between SecureSearch and Organization Name: Enter your Organization name (hereinafter called "Customer").

Select option that best describes your Company/Organization: * Invalid Input

Street Address* Enter the organization street address
City* Enter the organization city Select Organization state Zip* Enter the organization zip code
Main Phone* Enter the organization's main phone number Main Fax Invalid Input
CHOOSE PAYMENT METHOD * Credit Card or Invoice

Credit cards are charged on the 1st and 16th of each month for services ordered during the billing cycle. Cards that decline may be charged a $25.00 late fee.

Name as it appears on card:
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E-mail of card holder:
CC Number:
Exp. Date: Security Code:

Check if Billing Address is Same as Organization Address
Billing Address

Customer hereby allows SecureSearch to bill all monthly activity to Customer’s credit card. Customer agrees to pay a $25.00 penalty if insufficient funds are available. Customer also agrees that they are responsible for payment by alternate means of payment if credit card transaction is declined. If a credit card is not provided, we may request that a credit application be completed to establish a monthly billing account.

Invoiced clients are billed on the 1st of each month for services ordered the month prior. All invoices are sent via e-mail. Please provide two contacts for accounts payable or other responsible parties.

Name: Email Address: Phone: Ext.
Name: Email Address: Phone: Ext.
Authorized User(s) Information

Please tell us about the main contact on the account. This person will be the Administrative User. If you would like additional people to have access, please fill out the information below for General Users.

Administrative User: Can edit account information, add/suspend users, view/print invoices, and order services. This person should have management level responsibilities. This person will be responsible for alerting SecureSearch to User changes as well as our main contact.

Full Name:
Phone: Ext.

If you are unavailable, whom else may we speak with on your behalf? (IE: Administrative Assistant, Associate etc.)

Name: Email Address: Phone:

General User: Can order services, review profiles and has permission to discuss profile information with SecureSearch representatives. Various levels of access of the background screening information is available and can be different per user. Please contact our customer service team if you would like to discuss these options.

Full Name:
Phone: Ext.
Admin User?
Full Name:
Phone: Ext.
Admin User?
Full Name:
Phone: Ext.
Admin User?
Permissible Purpose

What is your permissible purpose, for ordering services with SecureSearch per the FCRA (§604. Permissible purposes of consumer reports [15 U.S.C. § 1681b])

Credit Reports
Terms of Relationship
Agreed to by

I hereby certify that I have direct knowledge of the facts stated above and that I am authorized to execute this Agreement on behalf of the Customer.

Please enter your name in the signature line.
Your Name
Please enter your title
Your Title
Please enter a valid email
Please enter your company name.
Organization Name
Choose * Invalid Input Invalid Input
Enter Number *
Customer agrees to the Agreement For Service* Invalid Input
Thank you for completing the following required* fields.
How did you hear about us? *

Please select an option
Which Insurance Company? *

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Please explain: *

Please provide
Referral *

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Has your organization been a client of SecureSearch in the past *

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All accounts are set up with our free paperless (electronic) consent. You can also print paper consent forms in lieu of using electronic consent. Access paper consent forms by clicking here.

Additional comments from customer