E-Sign Act Disclosure
If you do not consent to proceed electronically contact One Source at 1-800-608-3645, and reference Client ID SELFCHECK. You may now exit this page.

Total Check


Please read all instructions before completing this form!

The fee for the services provided by One Source is $39.00, plus Nebraska Sales Tax. Additional names and/or locations will be $10.00 each and court fees may apply. Payment 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: orders@onesourcebackground.com.

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Questions? Contact One Source at 402.933.9999 or 1.800.608.3645.
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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 aka first name. Do not enter nicknames such as Rob for Robert.
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.
Prior City
Prior State
Prior Zip Code
Prior Country CodePlease change if US is not the correct Country Code
SSNEnter social security number. Do not enter hyphens or dashes. EXAMPLE: 11122333
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
Did any indidvidual direct you to One Source for screening?Include name, website, organization or any information regarding lead source.
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