<< Back to Background Data Overview  
     
   
     
 
The information requested herein is required for account set-up and will be kept appropriately confidential. Please provide all information requested, including permissible purpose specifics. Banking information will be verified and references will be contacted. Background Data may require additional materials to satisfy federal and state compliance requirements. These materials may include specific certifications, examples of your End-User agreement, consumer authorization language or pre-adverse action notice, business license, professional literature or advertising. We will assist you to identify which additional materials, if any, may be required.
 
Bold fields are required.
 
Company Information
Company Legal Name:
Company Trade Name:
Physical Address:
(no PO boxes)
City:
State:
Zip:
Telephone Number:
Fax Number:
Website Address:
Mailing Address:
(if different from above)
City:
State:
Zip:
Company Contact Information
Name:
Title:
Email Address:
Telephone Number:
Billing Contact Information
Note: Invoices for NBD services will be sent via electronic mail only to the email address provided below.
Billing Contact:
Billing Email Address:
Billing Company:
(if other than Applicant)
Billing Address:
City:
State:
Zip:
Telephone Number:
Fax Number:
Compliance Contact Information
Note: Individual with responsibility for compliance issues such as consumer disputes or account audits.
Compliance Contact:
Compliance Email Address:
Compliance Mailing Address:
City:
State:
Zip:
Telephone Number:
Fax Number:
Other Company Information  
Parent Company:
(if applicable)
State of Registration/Incorporation:
Date Business Established:
Federal Tax ID:
(SSN, if Sole Proprietorship)
Type of Business:
Employment Screening Entity
Resident Screening Entity
Volunteer Screening Entity
Other FCRA Screening Entity
Non-FCRA Screening Entity
Which of the above is the PRIMARY Permissible Purpose?
Employment Screening Entity
Resident Screening Entity
Volunteer Screening Entity
Other FCRA Screening Entity
Non-FCRA Screening Entity
List/Describe all Activities for this Business:
Is this a home based business?
Yes
No
Does this business share office space with another business?:
(If "Yes", please provide details of the office sharing arrangements)
Yes
No
  Details:
Does this business have a PI license?:
Yes
No
  Expiration Date:
Professional organization membership(s):
NAPBS
SHRM
CDIA
Other (please identify)
 
 
Additional Compliance Materials
Provide three (3) trade references to verify the nature of the client's business activities. These references would be entities that you have an established business relationship with. Please notify all references that they will be contacted by NBD and request their prompt response.
 
Reference 1
Company Name:
Contact Name:
Address:
City:
State:
Zip:
Telephone Number:
Fax Number:
Nature of business relationship:
 
Reference 2
Company Name:
Contact Name:
Address:
City:
State:
Zip:
Telephone Number:
Fax Number:
Nature of business relationship:
 
Reference 3
Company Name:
Contact Name:
Address:
City:
State:
Zip:
Telephone Number:
Fax Number:
Nature of business relationship:
 
Bank Reference
Please fax a copy of a voided check/deposit slip to (877) 211-4804.
 
Bank Name:
Account Number:
Contact Name:
Contact's Title:
Address:
City:
State:
Zip:
Telephone Number:
Fax Number: