StafTrack, Inc. Verification / Reference Check List
Fax Completed Form to (727) 581-3725

Company Name:  __________________________________________________________
Contact Phone:  __________________ Ext. ______       Fax: _______________
Physical Location: __________________________________________________________
Due to the Proprietary nature of our reports and  databases, we are required to verify the validity of
the clients and corporations to which we disseminate information and do business with. Please complete
this check list answering all questions.

___Yes ___NO

___Yes ___NO

___Yes ___NO

___Yes ___NO

___Yes ___NO

___Yes ___NO

___Yes ___NO

Do you possess a valid business license?   If so please provide a copy.

Is the company actually locate at the stated address.

Is the company located in a commercial building as opposed to a private residence.

Is the company located in a commercial building as opposed to an apartment complex.

Is your office adjacent to, or the same as an attorney's office.

Is your company name / logo displayed conspicuously.

Do you have a Federal Identification Number? If so please provide it. ______________
If you do not have a Federal Identification Number then provide SSN. ______________

BANK REFERENCES
Please list two business credit references below. (Please indicate actual addresses, not P. O. box numbers.)

Bank Reference: _________________________________  Branch:_______________________
Telephone Number:________________________ Type of Account:_______________________

BUSINESS CREDIT REFERENCES
Please list two business credit references below. (Please indicate actual addresses, No P. O. boxes.)
Company Name:____________________________ Telephone:(___) _____________________
Company Address:______________________________________________________________
Company Name:____________________________ Telephone:(___) _____________________
Company Address:______________________________________________________________

PRINCIPALS OF THE COMPANY
Name:__________________________________________ Position:____________ Name:__________________________________________ Position:____________ Name:__________________________________________ Position:____________

I certify that I am one of the principles  named above. As a principal of_____________________
I authorize Staftrack, Inc. to verify the above information in conjunction with this application for
goods and services.

By:_______________________________________________ Title:_____________________