Contractor Screening Services Order Form


* Please fill out entire form & please be sure to provide the exact business name.

* If you would like to send this order form by fax, print and fax form to 954-530-3333.

We will contact you upon receipt and arrange for payment at that time.

* For your convenience, we accept : MasterCard, VISA, Discover, and American Express through PayPal.

Click "Buy Now" button at the bottom of the page and you will be taken to a secure page for payment.

We do not have access to or retain your credit/debit card information.

* $49.95 per report. To order multiple reports, fill complete separate form with separate payment.

If you have any questions, please feel free to call us 1-888-534-1212 or email:info@contractorscreeningservices.com


Customer

Name

Address

Suite

City

State

Zip Code

County

Contact #

Fax #

Email

Contractor

*Name

*Exact Business Name

*License Number

Business Phone

Business Address

City

State

Zip Code

*County

Insurance Company Name (if known)

Type of work to be performed