REQUEST FOR CRIMINAL HISTORY INFORMATION

PAGE ONE OF TWO PI#: ______

Company: Nicholas Carpet Care LLC To be completed and sent to:

Contact Person: Mark Nicholas PI Services LLC

29645 Rose Ln PO BOX 157

Wilsonville, OR 97070 Beaverton, OR 97075

Phone: 503-679-8226 503-643-4274 / fax-643-5474

Fax: _____-_____-______www. pi-info.com

Email:

TYPE your info on this form, then print for Signature

Full Name: ______Last First Middle

Date of Birth: ____/____/____ Social Sec#: _____-_____-_____ Phone: ______-______-______

00/00/00 ss# not needed for OR, WA & ID

Driver’s License #: ______State: ______Valid & Current: Yes ____ No ____

Current Address: ______

______First time background check for the above company, checking 10 year address history.

______Yearly renewal, only checking address history back to ______/______/______.

Maiden/Former Legal Name**: ______(if used in the past ten years for first time background check or in the last year if yearly renewal background check)

**Additional charges apply for additional names searched, see page 2.

FIRST TIME BACKGROUND CHECKS: LIST ALL CITIES, STATES AND DATES YOU HAVE RESIDED WITHIN THE PAST TEN YEARS. IF RENEWAL: LIST ALL FROM DATE OF LAST CHECK.

CITY & COUNTY STATE DATE ______

Portland-Multnomah EXAMPLE Oregon EXAMPLE Sept 2006 – Sept 2016

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Applicant’s signature I swear the above information is true and correct. Date Page 1 of 2

REQUEST FOR CRIMINAL HISTORY INFORMATION

PAGE TWO OF TWO

Have you been convicted of a crime in the past 10 years? Yes _____ No _____

Felony/Misdemeanor

If yes, when and where did the conviction take place?

______

______

First time background checks will be searched in all locations you lived in the last 10 years.

Yearly renewals will only be checked in locations lived in the last year or so since date of last background check. Price is for each name searched.

______Oregon Statewide $20.00

______Washington Statewide $25.00

______Idaho Statewide $20.00

______NW Statewide OR, WA & ID $50.00

______Other States: List State & County on page one.

Prices vary depending on location, we will invoice.

Payment Options:

___ Send an Invoice: We will invoice you. Fax, email or mail your form to our office.

Please make sure all your contact information on the first page is correct, Payment by check are due within 15 days of invoice.

___ Pre-Payment option 1: You can pay with a credit or debit card on our website.

After payment is made fax, email or mail your form to our office.

Prepayment confirmation #______

___ Pre-Payment option 2: Mail the form with a check, cash or money order to:

PI Services LLC PO BOX 157 Beaverton, OR 97075

______

Applicant’s Signature I swear the above information is true and correct. Date Page 2 of 2

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Date received:______Doc#______

CRIMINAL RECORD FOUND: No / Yes (If yes, see attached dockets sheet(s) with _____ record(s) found)

Date of search: ______Results sent to Client via: ______Fax or E-Mail______

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Each Background Check will have an invoice listing locations checked and results.

PI Services will keep a copy of this form on file for 90 days. After 90 days only the results & invoice will be kept on file.