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Card Billing Information and Application As a part of our quick approval and
payment protection plan, we require your credit card information. Instead of
completing a lengthy Account Application Form, All required Credit Card Number: ________________________________ Exp._____ / ______ Name On Card: _________________________________ CVV:_____________ Card Billing Address: ______________________________________________________ Street ______________________________________________________ City State ZIP_______________________________________________________ Name Of Company: ______________________________________________________ Type Of Company: Corporation Partnership Proprietor Others Tax ID#(TIN) or SSN:
_________________________________ * The card
number and your company information as well as TIN or SSN will be verified
within few hours. In order to verify your credit card and company information,
credit information will be accessed and verified. I hereby agree to the Service Agreement,
which I have electronically signed and submitted as well as the above terms
and conditions. I also authorize National Employment Screening DBA Premium
Background Checks to charge the payment according to the choice I made from
options above. National Employment Screening DBA Premium Background Checks 5700 Memorial Hwy Suite 111 Tampa Fl, 33615 Tel: 1-800-459.3034 Please complete and Fax to our South Florida Office at: 1.305.852.6010
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