APPLICATION FOR BACKGROUND CHECK 

Name: ___________________________________________________________________________________

Address: ________________________________________________________________________________

City: _____________________________________   State: _________  Zip Code: _______________

Home Phone: ______________________ Business Phone: _______________ Fax: _________________

Soc. Sec. Number: __________________________________  Birthdate: ________________________

Driver's License Number: ________________________________________________________________

Email Address: _________________________________ Choose Password: _______________________

I hereby authorize Allison & Taylor and its agent(s) to contact the following 
source(s) for purposes of verifying any background information requested.  I understand 
that Allison & Taylor cannot and does not guarantee that any specific results will 
be obtained, nor that work will be completed within any specific time period.  I 
nderstand that Allison & Taylor will document its findings to the best of its 
ability.  I affirm that the information I have provided herein is, to the best of my 
knowledge, true, complete and accurate.  We are not responsible if incorrect numbers 
are supplied and we need to re-conduct the search again.

Client Signature:  _____________________________________________  Date: _________________

Please check the service(s) you wish us to provide on your behalf. In addition to fee 
below please add $25 admin fee:

Payment: We take major credit cards including Master Card, American Express,
Visa, Discover and Debit Cards

Number of Checks Ordered:  ____________________   Total Cost: ___________________________

Please check one:  Visa  MasterCard  Amex  Discover  Check  Money Order

Credit Card Number: _____________________________________   Expiration Date: ____________

Card Holder's Name: _____________________________________________________________________

Signature: ________________________________________________    Date: ____________________

Any questions?  Call 800-890-5645. Costs are per search or as otherwise indicated.
Check and/or money orders should be payable to Allison & Taylor  Be sure to
sign and complete this form.  All materials can be faxed to 248-460-4300 or mailed to
Allison & Taylor, 301 William Rd., Rochester, MI 48307. 
All corporate accounts must provide a copy of signed job application.

APPLICATION FOR REFERENCE VERIFICATION
Name: ________________________________________ Soc.Sec. Number: _________________________

Address: ________________________________________________________________________________

City: _____________________________________ State: __________ Zip Code: _________________

Home Phone: ___________________ Business Phone: _________________ Fax: __________________

Email Address: __________________________________ Choose Password: ______________________

I hereby authorize Allison & Taylor and its agent(s) to contact the following 
source(s) for purposes of verifying any reference, recommendation or statements related 
to my employment. I understand that Allison & Taylor cannot and does not guarantee 
that any specific results will be obtained, nor that work will be completed within any 
specific time period. I understand that Allison & Taylor will document its findings 
to the best of its ability. I affirm that the information I have provided herein is, to 
the best of my knowledge, true, complete and accurate.

Client Signature: _________________________________________________ Date: _______________

List the contact information for each reference and attach additional sheets as necessary.

Contact Name: _____________________________________ Title: ______________________________

Company Name: ___________________________________________________________________________

Company Address: ________________________________________________________________________

City: ______________________________________ State: ___________ Zip Code: _______________

Phone: (direct line if possible) _________________________ Fax: _________________________

Your Position Title: _____________________________ Dates of Employment: _________________

Salary to be confirmed (Executive level only): __________________________________________

Relationship with Contact: (Superior, Colleague, etc.) __________________________________

Reason you left this company: ___________________________________________________________

List a position title for which you are being considered: _______________________________

List any other information you feel is pertinent: (attach additional pages if necessary):

_________________________________________________________________________________________

We would like a copy of your resume, if available.

Payment: The fee for each Professional Level reference check is $79.00 and each Executive 
Level reference check is $99.00. A full written report will be available online at 
www.AllisonTaylor.com

Rush service is available for an additional fee of $25.00 per reference ordered. 
Telephone, mail and fax reports are each available for an additional $10.00 per 
reference. International calls will be charged an additional $30.00 per reference. 
Personal checks, Visa, Master Card, American Express and money orders are accepted.

Please choose:  Professional Level ($79 each)  Executive Level ($99 each)

Would you like:  Rush Service ($25)  Fax Report* ($10) 
                 Mail Report ($10)   Telephone Report* ($10)

*Are your phone/fax numbers confidential? Do we need to call prior to sending a fax? ____

Where did you learn of our service? (Attorneys’ name and number who referred you to us)

Name: __________________________________________ Telephone Number: ______________________

We take major credit cards including Master Card, American Express, Visa and Debit Cards

Number of Checks Ordered:  ___________________________  Total Cost: _____________________

Please check one:  Visa  MasterCard  AmEx   Discover  Check  Money Order

Credit Card Number: _____________________________________   Expiration Date: ____________

Card Holder's Name: _____________________________________________________________________

Signature: ________________________________________________    Date: ____________________

Any questions? Call 800-890-5645. Check and/or money orders are payable to Allison & 
Taylor Be sure to sign and complete this form. Attach a copy of your current 
resume, if available. All materials can be faxed to 
248.460.4300 or mailed to Allison & Taylor, 301 William Rd., Rochester, MI 48307.

ADDITIONAL REFERENCES TO BE CHECKED

List the contact information for each reference and attach additional sheets as necessary.

Contact Name: _____________________________________ Title: ______________________________

Company Name: ___________________________________________________________________________

Company Address: ________________________________________________________________________

City: ______________________________________ State: ___________ Zip Code: _______________

Phone: (direct line if possible) _________________________ Fax: _________________________

Your Position Title: _____________________________ Dates of Employment: _________________

Salary to be confirmed (Executive level only): __________________________________________

Relationship with Contact: (Superior, Colleague, etc.) __________________________________

Reason you left this company: ___________________________________________________________

List a position title for which you are being considered: _______________________________

List any other information you feel is pertinent: (attach additional pages if necessary):

_________________________________________________________________________________________

Contact Name: _____________________________________ Title: ______________________________

Company Name: ___________________________________________________________________________

Company Address: ________________________________________________________________________

City: ______________________________________ State: ___________ Zip Code: _______________

Phone: (direct line if possible) _________________________ Fax: _________________________

Your Position Title: _____________________________ Dates of Employment: _________________

Salary to be confirmed (Executive level only): __________________________________________

Relationship with Contact: (Superior, Colleague, etc.) __________________________________

Reason you left this company: ___________________________________________________________

List a position title for which you are being considered: _______________________________

List any other information you feel is pertinent: (attach additional pages if necessary):

_________________________________________________________________________________________

Contact Name: _____________________________________ Title: ______________________________

Company Name: ___________________________________________________________________________

Company Address: ________________________________________________________________________

City: ______________________________________ State: ___________ Zip Code: _______________

Phone: (direct line if possible) _________________________ Fax: _________________________

Your Position Title: _____________________________ Dates of Employment: _________________

Salary to be confirmed (Executive level only): __________________________________________

Relationship with Contact: (Superior, Colleague, etc.) __________________________________

Reason you left this company: ___________________________________________________________

List a position title for which you are being considered: _______________________________

List any other information you feel is pertinent: (attach additional pages if necessary):

_________________________________________________________________________________________

All materials can be faxed to 248.460.4300 or mailed to Allison & Taylor, 
301 William Rd., Rochester, MI 48307