Information, Reporting & Billing Form

Service or Background Screening Requested:

Payment Information

Name to address faxes to
Number & Street
Address Line 2
A copy of this form will be sent to this email address

Credit Card Payments

3-Digit number on back of card
(If different than Billing Address above)
I authorize payment of services to be charged to my credit card as services are provided. I am the authorized signer.

Authorized person(s) to receive background or drug screen results by secured method:

NOTE: If at any time the authorized persons to receive background or drug screen results changes you are responsible for contacting Universal Screen. If you have any questions, please contact Lucy @ (931) 489-0045.