Please make sure to include a copy of your business license with this application.
MPIS
MEMBERS NAME: _______________________________________
COMPANY NAME: _______________________________________
STREET ADDRESS: _______________________________________
CITY/STATE/ZIP: _________________________________________
TELEPHONE NUMBER: ______________________________
This has been set forth by MPIS and:
Your name: ______________________________ Title: ________________ Date: ___________
If partnership (Please provide second name, and contact)
Your name: ______________________________ Title: ________________ Date: ___________
Who will be MPIS's main contact at your company?_____________________________________________
Type of Ownership: (check one) _____Corporation _____Partnership _____Sole Owner _____Non-Profit
Other business name(s) or dba: _________________________________________________________________
Physical Address:_____________________________________________________________________________
City:_________________________________________ State:________ Zip Code:__________________
Phone: (_____)________________ Fax: (_____)________________
E-mail address:_______________________________ Web Site URL:_____________________________________
Have you previously been a MPIS Subscriber? _____Yes _____No
If YES, under what name?_______________________________________________________________________
Principal name:___________________________________________ Title:________________________________
Social Security #:_____________________________________
Residential Address:______________________________________________________________________________
Type of business:________________________________________________________________________________
What type of reports are you primarily interested in receiving from MPIS? (Please describe fully)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
How will you access MPIS reports? _____FAX _____PHONE ________ EMAIL _________INTERNET
Enter fax, phone, or email address where reports will be sent _____________________________________________
Is your company tax exempt? ____Yes ____No If yes, please provide documentation.
Billing Address (please complete if different from above)
Contact Name:_____________________________________________ Phone: (_______) ______________________
Address:__________________________________________________ Fax: (_______) ________________________
City:_________________________________________ State:_______ Zip Code:_________________
MPIS Subscriber Agreement, Addendum A - Access and Use of Consumer Reports for purposes OTHER than Employment Screening
REQUIRED
Subscriber understands that
Subscriber is a _____________________________ (business type) and has a permissible purpose for obtaining consumer reports, as defined by Section 604 of the Federal Fair Credit Reporting Act (15 USC 1681b) as amended by the Consumer Credit Reporting Reform Act of 1996, hereinafter called "FCRA." The subscriber certifies their permissible purpose as: (check all that apply)
_____ In connection with a credit transaction involving the consumer on whom the information is to be furnished and involving the extension of credit to, or review or collection of an account of the consumer; or
_____ In connection with the underwriting of insurance involving the consumer or review of existing policy holders for insurance underwriting purposes, or in connection with an insurance claim where written permission of the consumer has been obtained; or
_____ In connection with a tenant screen application involving the consumer; or
_____ In accordance with the written instructions of the consumer; or
_____ For a legitimate business need in connection with a business transaction that is initiated by the consumer; or
_____ As a potential investor,
Subscriber certifies that it will request consumer reports pursuant to procedures prescribed by Reseller from time to time only for the permissible purpose certified above, and will use the reports obtained for no other purpose.
Subscriber will maintain copies of all written authorizations for a minimum of three (3) years from the date of inquiry.
THE FCRA PROVIDES THAT ANY PERSON WHO KNOWINGLY AND WILLFULLY OBTAINS INFORMATION ON A CONSUMER FROM A CONSUMER REPORTING AGENCY UNDER FALSE PRETENSES SHALL BE FINED UNDER TITLE 18, OR IMPRISONED NOT MORE THAN TWO YEARS, OR BOTH.
Subscriber agrees that it shall use Consumer Report only for a one-time use, and to hold the report in strict confidence, and not to disclose it to any third parties; provided, however, that Subscriber may, but is not required to, disclose the report to the subject of the report only in connection with an adverse action based on the report.
With just cause, such as delinquency or violation of the terms of this contract or a legal requirement, Reseller may, upon its election, discontinue serving the Subscriber and cancel this Agreement immediately.
I agree to the terms and conditions set forth in the MPIS Subscriber Agreement - Addendum A.
| MPIS | Subscriber Company: | _________________________________ |
| By: | __________________________ | By: | _________________________________ | |
| Title: | __________________________ | Title: | _________________________________ | |
| Date: | __________________________ | Date: | _________________________________ |
MPIS Subscriber Agreement, Addendum B
- Access and Use of Consumer Reports for the sole purpose of Employment Screening
Subscriber understands that
Subscriber is a _____________________ (business type) and has a need for consumer credit information in connection with the evaluation of individuals for employment, promotion, reassignment or retention as an employee ("Consumer Report for Employment Purposes").
Subscriber shall request Consumer Report for Employment Purposes pursuant to procedures prescribed by Reseller from time to time only when it is considering the individual inquired upon for employment, promotion, reassignment or retention as an employee, and for no other purpose.
Subscriber certifies that it will not request a Consumer Report for Employment Purposes unless:
A. A clear and conspicuous disclosure is first made in writing to the consumer before the report is obtained, in a document that consists solely of the disclosure, that a consumer report may be obtained for employment purposes;
B. The consumer has authorized in writing the procurement of the report; and
C. Information from the Consumer Report for Employment Purposes will not be used in violation of any applicable federal or state equal employment opportunity law or regulation.
Subscriber further certifies that before taking adverse action in whole or in part based on the Consumer Report for Employment Purposes, it will provide the consumer:
A. A copy of the Consumer Report for Employment Purposes; and
B. A copy of the consumer's rights, in the format approved by the FTC, which notice shall be supplied to Subscriber by Reseller.
Subscriber agrees that it shall use Consumer Report for Employment Purposes only for a one-time use, and to hold the report in strict confidence, and not to disclose it to any third parties not involved in the current employment decision.
Subscriber will maintain copies of all written authorizations for a minimum of three (3) years from the date of inquiry.
With just cause, such as delinquency or violation of the terms of this contract or a legal requirement, Reseller may, upon its election, discontinue serving the Subscriber and cancel this Agreement immediately.
I agree to the terms and conditions set forth in the MPIS Subscriber Agreement - Addendum B.
| MPIS | Subscriber Company: | _________________________________ |
| By: | __________________________ | By: | _________________________________ | |
| Title: | __________________________ | Title: | _________________________________ | |
| Date: | __________________________ | Date: | _________________________________ |
MPISis authorized to charge my credit card/ Debit card for ongoing services provided to my company's authorized users of MPIS Daily/Weekly/Monthly
Cardholder Signature_______________________________________________________________________________
Credit Card Info: VISA
Mastercard
Discover
(circle one)
Name of Cardholder________________________________________________________________________________
Card #____________________________________________________________ Exp. Date_____________________
Cardholder Address________________________________________________________________________________
To pre pay you may mail this form with a check, or money order
to:
MPIS, Inc
Grand Central Business Center
Suite 3100
Keyser, WV 26726
I authorize MPIS to check all records, and possibly credit to process this account.
What is your Federal Tax ID number: ________________________
What username would you like: ____________________
What would you like your password to be: ___________________
Please keep your username, and password in a safe place.
Signature : ______________________________________ Date: ____________
Title: __________________________________