E-Sign Act Disclosure
If you do not consent to proceed electronically contact One Source at 1-800-608-3645, and reference Client ID SELFBASIC. You may now exit this page.
Please read all instructions before completing this form!
The fee for the services provided by One Source is $15.00 including Nebraska Sales Tax, payment for which is made directly to One Source and accompanies this request.
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.
Email One Source with any special notes/comments regarding this applicant at:
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Questions? Contact One Source at 402.933.9999 or 1.800.608.3645.
Process Credit Cards
Enter full legal first name.
Enter middle name or initial.
Enter full legal last name.
Enter suffix if applicable. EXAMPLE: Jr., Sr., III
Full Street Address
Zip Code Notes
Please change if US is not the correct Country Code
Enter 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
Enter a phone number the applicant can be reached at between 8 am and 5 pm.
Enter an email address. REQUIRED for e signature on release
Did any indidvidual direct you to One Source for screening?
Include name, website, organization or any information regarding lead source.
Basic Check 2.0
County Criminal - Statewide If Available