Home | January 5, 2009 
Workers Compensation Search Order Form
Please enter your applicant's information below. Bold fields are required. If you are providing an alternate address, please enter it in the 'Comments' section.
   
Title:
First Name:
Middle Name
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip:
Date of Birth:
SSN: (xxx-xx-xxxx)
Gender:
Race:
State Worked In:
Comments:
   
The States of AK, AL, IA, MN, MO, OK, PA, UT, and VA all require a special signed release form. Click here to get those special forms.

 

 

All other states require a standard signed release form. Click here to get the standard release form.

 

 

I have given this applicant a conditional job offer and will fax this WC release form today to 607-936-2300.