Submit Background Check Request — Blue Check Background

1

Personal Information

First Name * First name is required.

Last Name * Last name is required.

Nickname / Alias

Date of Birth * Date of birth is required.

Place of Birth * Place of birth is required.

Gender at Birth

Race

White

Originating from Europe, the Middle East, or North Africa.

Black or African American

Originating from any black racial groups of Africa.

Asian

Originating from the Far East, Southeast Asia, or the Indian subcontinent.

American Indian or Alaska Native

Indigenous to North, Central, or South America with tribal affiliation.

Native Hawaiian or Other Pacific Islander

Originating from Hawaii, Guam, Samoa, or other Pacific Islands.

Middle Eastern or North African (MENA)

A distinct category representing origins in the Middle East or North Africa.

Other Race

Does not identify with any of the above categories.

Current Street Address * Address is required.

City

State

Zip Code

Social Security Number *

SSN is required.

Re-enter Social Security Number *

Please re-enter your SSN.

Current Phone Number * Phone number is required.

Cell Number * Cell number is required.

E-mail Address * A valid email address is required.

Company / Organization Name * Company / organization name is required.

Organization City & State * Organization city and state is required.

Organization Contact Name * Organization contact name is required.

Organization Contact Phone * Organization contact phone is required.

2

Arrest & Conviction History

Answer all questions truthfully. Providing false information may result in disqualification. All answers are confidential.

Have you ever been arrested by Federal or Military Law Enforcement? *

Yes No

Alleged Federal/Military Charges

Were you convicted in Federal or Military Court? *

Yes No

Have you ever been arrested by State, County, City, Town or Village Law Enforcement? *

Yes No

Alleged State/Local Charges

Were you convicted in State, County, Town, City or Village Court? *

Yes No

Are you required to register on any offender registries? *

Yes No

3

Consent & Waiver Agreement

Background Check Authorization & Release

The BlueCheck Portal is for background reviews conducted within the United States. By submitting this form, I authorize BlueCheck and its processing agents to conduct a background review on my behalf.

I understand that billing statements will reflect the name of the processing agency. I acknowledge that the accuracy of my background review report depends entirely upon the accuracy of the information I have provided herein.

No promises or guarantees have been expressed orally or in writing regarding the outcome of this background review, and no representations have been made to me regarding the use of this information beyond the stated purpose of organizational membership review.

I hereby consent and authorize BlueCheck and its employees and agents to provide the contents of my background review report to the company or organization I have named in this form, and to any authorized representatives thereof who have a legitimate need to review such information.

I hereby release, discharge, and hold harmless BlueCheck, its employees, agents, officers, and all cooperating agencies from any and all liability, claims, or causes of action arising out of the collection, processing, and disclosure of information contained in this background review.

I certify that all information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in my disqualification for membership and may subject me to other appropriate actions.

I understand that this authorization will remain valid for the purpose of this specific background review request only.

By checking the box below and submitting this form, I confirm that I have read, understood, and agree to the terms of this Background Check Authorization & Release.

I acknowledge and agree to the above Background Check Authorization & Release.

I certify that all information provided is true and accurate to the best of my knowledge. I understand that providing false information may result in disqualification.

You must accept the terms to continue.

4

Billing & Payment

Select Review Type *

Standard Review

Turnaround: 3–7 business days

$45.00

State & local criminal records
Federal criminal records
Sex offender registry check

✓ Selected

Deep Review

Turnaround: 5–10 business days

$125.00

Everything in Standard
Enhanced multi-state search
Extended history coverage

Select

Processing Fee

Standard Review

$45.00

Promo Code

First Name * Billing first name is required.

Last Name * Billing last name is required.

Billing Address * Billing address is required.

City * City is required.

State

Zip Code

Phone Number * Phone number is required.

E-mail Address * A valid billing email is required.

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