APPLICATION FOR SERVICES
Please print this form out, complete and send to the following address:
Nationwidesearch  MPIS
Post Office Box 279
Keyser, WV 26726-0279

You will receive feedback from us within 15 days.
Name of Firm (or DBA if Applicable) Telephone Number

(     )
Physical Address Fax Number

(     )
City State Zip E-Mail Address
Billing Address , if different FEIN (or SSN if Sole Proprietorship)
 
Billing Contact Telephone Number, if different

(     )

Corporation

Partnership

Sole Proprietorship

In Business Since

Number of Employees

Is Business Home-Based?

BUSINESS LICENSE – Please attach a copy of your license
City, County, State of Issue

 License Number On File where?

Please Check ALL of the Categories Below That Describe Your Business

o Attorney/Legal o Security Agency o Investigation

o Insurance o Government o Finance/Collection

o Corporations

o Other (Describe) ___________________________________________________________________________________________________________

 

 

Credit Card Information: o VISA o M/C o Discover

Credit Card Number Exp Date Name Exactly as it appears on Card
Bank Name
 Bank Address
Contact Name Telephone Number

(     )

 Type and Account Number
THREE BUSINESS CREDIT REFERENCES
Company Name Contact Name
Account Number Telephone Number
Address City, State, Zip
Company Name Contact Name
Account Number Telephone Number
Address City, State, Zip
Company Name Contact Name
Account Number Telephone Number
Address City, State, Zip

As part of your application for services, we may be required to verify credit information, business references and a bank reference on your company. If your business is incorporated, an officer of the corporation must sign below to authorize us to access this information as necessary.

 

___________________________________________________________________________ _________________________

Signature Title Date

 

We strive to achieve and enforce the highest level of legal and ethical conduct in the use of its information products. We seek to tailor our products and to strictly limit access to them in a fair and balanced manner that respects both legitimate needs for information and legitimate privacy expectations. The following notice is provided to you so that you may avoid falling under the restrictions imposed by the Fair Credit Reporting Act (FCRA).

Our products must only be used to locate or further identify the data subject and should not be used in whole or in part to determine consumer eligibility for credit, employment, or insurance or any other purpose for which a consumer report would be obtained, except in connection with collection of a debt. If adverse action is to be taken against a consumer data subject and the information to be used has been obtained from us, it must be verified from another source prior to adverse action. Information obtained from our database products is to be used for lead information only.

Please indicate the purposes for which you will access our databases by selecting all that apply from the list below.

 

_________________________________________ ______________________________________

Company Name Typed or Printed Name Authorized Signer

_________________________________________ _______________________________________

Signature Title

_________________________________________ _______________________________________

Tax ID Date