SecurHomeland
Criminal History Search Request Form

All information must be completed to conduct the criminal history search.

Applicant's First Name

Applicant's Middle Name, if any

Applicant's Last Name

Applicant's Maiden Name

Other Names Used by Applicant

Applicant's Social Security Number

Applicant's Date of Birth (mmddyyyy)

Applicant's Street Address:

City

State

ZIP Code:

Applicant's Email (Important for real-time communication with applicant):


The applicant (or employee) has signed the "SecurTest Employment Subscriber Application and Service Agreement" agreeing to the terms and conditions set forth therein. I certify that the subject of this request is an applicant for employment or an existing employee and that as the employer we are responsible for following the Fair Credit Reporting Act and other applicable laws and have a "permissable purpose" to receive the report in accordance with the FCRA.
I certify that this request is an applicant for employment or existing employees ONLY. Yes

I further certify that if adverse criminal history information is reporting by SecurTest that I will give the applicant SecurHomeland^Verify to authenticate the criminal history within 3 business days. I agree to fax or mail a copy of the SecurTest authorization upon request by SecurTest, marking the form SUBMITTED ONLINE in the upper right corner. I agree to take no adverse employment action where the applicant or employee disputes the accuracy of the SecurHomeland Report until such time that SecurTest has re-investigated the disputed data. I understand that SecurTest may require the form to be faxed to (813) 889-8200 before processing my request. Yes