Membership Application
Version 4.2015
Company Name: ___________________________________________ Also Doing Business as: __________________________
Contact Name: _____________________________________________ Title: _________________________________________
Company Main Phone #: _____________________________________ Web Page Address:_______________________________
Physical Address: Billing Address:
Street Street
City State County Zip City State County Zip
**** Nature of Business: _______________________________________ Date Established: ______________________________
**** Intended use of Product(s): Pre-Employment Tenant Franchisee
Is the company exempt from sales tax?
If "Yes
"
provide the appropriate resale or exemption certificate(s). Yes No
Is the applicant engaged in the underwriting of insurance? Yes No
Is the company licensed or providing service as an attorney or detective/investigative agency?
If "Yes" indicate which: ____________________________________________________________ Yes No
Does the company intend to resell or release information from the consumer credit report to a third party? Yes No
Does the company provide credit repair or credit services for a fee? Yes No
Will the company, or does the company have an Internet Web site address?
If "Yes" please list site address ______________________________________________________ Yes No
Is the business:
A publicly held company under the regulatory authority of the US Securities and Exchange Commission? Yes No
Listed in the Financial Industry Regulatory Authority’s (FINRA) publication OTC Bulletin Board (OCTBB)? Yes No
Subject to the regulatory authority of any agency listed in Section 621(b) of the FCRA, 15 U.S.C § 1681s(b)? Yes No
A licensed insurance company? Yes No
Approved by the Internal Revenue Service as a tax-exempt organization pursuant to Section 501(c)(3) of
the Internal Revenue Code 26 U.S.C. § 501(c)(3)? Yes No
Certified by the Small Business Administration for participation in an SBA-administered program? Yes No
Certified by the by the Department of Transportation for participation in the Department of Transportation’s
Disadvantaged Business Enterprise Program? Yes No
A Federal or State Agency? Yes No
A franchise recreational vehicle dealership (auto and motorcycle dealerships excluded) that can be
verified as such through the direct manufacturer’s website? Yes No
A franchise auto dealership that can be verified as such through the direct manufacturer’s website? Yes No
A mortgage broker and works from a residential site with proper verification? Yes No
Membership Application
Version 4.2015
Please indicate if your business is categorized as:
Adult entertainment service of any kind
Yes No
Asset location service
Yes No
Attorney or Law Firm engaged in the practice of law, unless engaged in collection or
using the report in connection with a consumer bankruptcy pursuant to the written
authorization of the consumer.
Yes No
Bail Bondsman, unless licensed by the state in which they are operating
Yes No
Child location service Company that locates missing children
Yes No
Credit counseling, except not-for-profit credit counselors
Yes No
Credit repair clinic
Yes No
Dating service
Yes No
Financial counseling, except a registered securities broker dealer or a certified financial
planner
Yes No
Foreign company or agency of a foreign government
Yes No
Genealogical or heir research firm
Yes No
Law enforcement agency
Yes No
Massage service
Yes No
News agency or journalist
Yes No
Pawn shop
Yes No
Private detective, detective agency or investigative company
Yes No
Repossession company
Yes No
Subscriptions (magazines, book clubs, record clubs, etc.)
Yes No
Tattoo service
Yes No
Time Shares - Company seeking information in connection with time shares (exception:
financers of time shares)
Yes No
Weapons dealer, seller or distributor
Yes No
Other Reseller
Yes No
If you are an attorney, law firm, law enforcement agency, private detective, detective agency, investigative company, insurance
company, security service, or weapons dealer, please indicate the intended use of the products:
________________________________________________________________________________________________________
Membership Application
Version 4.2015
Signature: _______________________________________ Date: ___________________________________________
Print Name: _______________________________________ Title: ___________________________________________
** Return via E-mail to credentialing@intellicorp.net or Fax to 216-450-5105. **
This section to be completed by ‘Corporation’
Officer Name: __________________________________ Title: ______________________________
Officer Name: __________________________________ Title: ______________________________
Officer Name: __________________________________ Title: ______________________________
Federal Tax Identification Number: ___________________________
This section to be filled out by ‘Sole Proprietors’ or ‘Partnerships’ (Please circle appropriate business type)
Owner Name: _______________________________________________________________________________
Residence: __________________________________________________________________________________
Social Security #:______________________ Signature: _______________________________________
Federal Tax Id: ________________________
Owner Name: _______________________________________________________________________________
Residence: _________________________________________________________________________________
Social Security #:______________________ Signature: ______________________________________
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