Residential Screening Request

Screening Request Form

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

SSN

DOB

Home Phone

Mobile Phone

Email

Have you ever been arrested before?

Community Name

Zelle Email or Telephone

*** AmeriCheckUSA will send you a Zelle payment request. Please accept to issue payment so that we may process your background check in a timely manner. Thank You.

Disclosure / Authorization

DISCLOSURE

AmeriCheckUSA may request one or more consumer reports or investigative consumer reports about you for employment or residential purposes. These reports may include information on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which may be used as a factor in making an employment or residential related decision about you. Such information may include credit reports, criminal history, civil records, etc. or personal interviews with your current or prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information.

Authorization

By signing below, I agree that I have read and understand the foregoing Disclosure and hereby authorize AmeriCheckUSA to obtain consumer reports or investigative consumer reports about me for employment or residential purposes. I further authorize AmeriCheckUSA to share the information with any person involved in the employment or residential decision about me. This agreement will not be valid after 90 days of date signed, and you also agree that a fax or photocopy of this authorization with your signature be accepted with the same authority as the original.

READ, ACKNOWLEDGED AND AUTHORIZED

Name (One Person Per Form)

ever ACKNOWLEDGED Telephone

Signature

Clear Signature

Signature (One Person Per Form)

Date Signed

Drivers License

Upload Drivers License (Required)

Click or drag a file to this area to upload.

Allowed file types: .jpg, .png, .pdf