ICU Investigation Request Form

Screening Services
Powered by: ICU Investigations
Fill out the following form to request background check services.

856-988-6777

( Use Your TAB key or mouse to advance to the next field. Do Not Hit Enter! )
* - REQUIRED FIELD!

REQUESTER INFORMATION

Check the services requested. Be sure to check all that you require!

Nation Scan	Social Security	Credit Check	County Criminal
State Criminal	Fed Criminal	Sex Offender	Employment

APPLICANT INFORMATION

* Applicant's Name:
Any Other Names /Maiden/AKA:
Full Address (No PO Boxes):
Previous Address:
* Social Security Number:
Date Of Birth:
Drivers License Number & State:
Professional Lisences/RN/CCM/CRC/other:

EMPLOYMENT INFORMATION
(Most Current Employers "Authorized To Contact")

(1) Name Of Employer/Temp Service:
Address:
Telephone Number:
Contact Name:
Position Held:
Dates Employed (starting & ending):
Reason for Leaving:

(2) Name Of Employer/Temp Service:
Address:
Telephone Number:
Contact Name:
Position Held:
Dates Employed (starting & ending):
Reason for Leaving:

(3) Name Of Employer/Temp Service:
Address:
Telephone Number:
Contact Name:
Position Held:
Dates Employed (starting & ending):
Reason for Leaving:

Review and insure all information is correct, then click "Submit".