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MRBA Member - New Client Set-Up Form 
Please Complete and FAX to 800-844-2722 MRBA Member Information: Member Name______________________________________________________________________ Address____________________________City________________________State ___ Zip_________ Billing Address: ____Same As Above OR Address____________________________City________________________State ___ Zip_________ Phone_____________________Fax_________________________Email________________________ Primary Contact_______________________________ Title__________________________________ Billing Contact________________________________ Title__________________________________ # of Employees ______ Approximate Annual Employee Turnover Rate ______% Employment Screening Services: We expect to order the following Employment Screening Services:
Ordering/Result Reporting Details (check all that apply): Ordering EMPLOYMENT SCREENING (check all that will apply): ___We will order screenings via the LABORCHEX website ___We will FAX orders ___We will Mail orders Receiving/Reviewing EMPLOYMENT SCREENING Results (check all that will apply): ___We will check the website NOTE: Most LABORCHEX clients that use the website to order screenings and receive/review results also choose to receive results via Email or FAX. ___Email results to persons indicated below ___FAX results to persons indicated below ___CALL before FAXing Employment Screening Contacts: Name:___________________Email:___________________Phone:____________FAX:____________ ____Order Screenings ____Receive Results ____BOTH Name:___________________Email:___________________Phone:____________FAX:____________ ____Order Screenings ____Receive Results ____BOTH Name:___________________Email:___________________Phone:____________FAX:____________ ____Order Screenings ____Receive Results ____BOTH Name:___________________Email:___________________Phone:____________FAX:____________ ____Order Screenings ____Receive Results ____BOTH (please use a separate sheet for additional names) |