Landmark Insurance Associates
Resisting Evil Workshop
Background Check Request
Background Check Request Form
If you are human, leave this field blank.
Background Check Information
Please provide information on the person you are requesting a background check on. *****Only one person per request, add additional people by clicking on 'Add' button at bottom of page***** NOTE: We take your private information seriously, this information is submitted through our secure website and not emailed for that very reason. If you have any questions, please contact us 877-747-1982 or firstname.lastname@example.org.
First and Last name of the person you are requesting the background on *****Only one person per request***** Additional requests can be made by clicking on"Add" button at the bottome of this page.
Social Security Number
Date of Birth
Male or Female?
Current Physical Address
Enter Driver's License Number (Only if requesting MVR check)
Authorization and release (Please click on the appropriate statement)
I am the person for which the background is to be conducted and I hereby authorize the background report
I represent the organization and hereby declare that I have obtained a signed release from the person for which the background is being reqeusted.
Click on "Add" button for additional requests. Click on "Submit" once all requests have been entered.
Billing & Report Contact Info
Please provide your billing and point of contact information.
Please check the desired reports:
* Criminal Background Report $18.50
US Mailing Fee +$1
Credit Check + $10
Motor Vehicle Report +$5
Name of your Church (Organization)
Your Name Billing Contact)
Billing Mailing Address
Billing Phone Number
Billing Email Address