E-Sign Act Disclosure
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Total Check

Refugee Empowerment Center

Please read all instructions before completing this form!

Once you submit your One Source background check, you will receive a supplemental email directly from to complete your Nebraska Adult and Child Abuse registry check.

The following information may be required by law enforcement agencies, local, state or federal governmental agencies or similar public bodies for positive identification purposes when checking public records. I understand that this information is confidential and will only be used for background screening purposes.

According to the Fair Credit Reporting Act you are to be provided with a copy of your rights according to the FCRA. Please click here for the Summary of Consumer Rights According to the FCRA.

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First NameEnter full legal first name.
Middle NameEnter middle name or initial.
Last NameEnter full legal last name.
SuffixEnter suffix if applicable. EXAMPLE: Jr., Sr., III
AKA First NameEnter Previous Maiden or Legal Names, Do NOT enter Nicknames
AKA Middle NameEnter aka middle name or initial.
AKA Last NameEnter aka or maiden name if applicable.
Street AddressFull Street Address
Zip Code Zip Code Notes
Country Code Please change if US is not the correct Country Code
Prior Street AddressEnter prior full address, only if outside of Nebraska in the last 7 years
Prior City
Prior State
Prior Zip Code
Prior Country CodePlease change if US is not the correct Country Code
Request Copy ?Would you like a copy of the report ?
SSNEnter social security number. Do not enter hyphens or dashes. EXAMPLE: 11122333
Birth Date (DOB)Enter date of birth. Do not enter hyphens or dashes. EXAMPLE: 12101970
Drivers License NumberEnter Drivers License Number.
Issuing StateEnter Drivers License Issuing State.
Phone NumberEnter a phone number the applicant can be reached at between 8 am and 5 pm.
Email AddressEnter an email address. REQUIRED for e signature on release
  Basic Enhanced 1.1
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  County Criminal - Statewide If Available  Motor Vehicle Record
  NE Adult Abuse Registry 1.0  NE Child Abuse Registry 1.0