Consumer Authorization
Pre-Employment Screening Payment
All fields marked with an * are mandatory.
"
*
" indicates required fields
Name
*
First
Last
Company (or Company Partnering With)
Are you an NEMT Driver?
*
Yes
No
Who is the background for?
*
Verida Only
Modivcare Only
Verida and Modivcare
Phone
*
Email
*
Service Requested
*
Invoice
Background Services
Background Services (Arkansas only)
Background Services (Oklahoma only)
Background Services (Tennessee only)
Background Services (Virginia only)
Invoice Payment
Invoice Number
*
Account Number
Invoice Amount
*
Nationwide
Quantity
Price:
$18.00
Quantity
This rush fee is per background screening. We will return the background report within twenty-four hours.
Rush Nationwide Background Screening(s)
This rush fee is per background screening. We will return the background report within twenty-four hours.
Motor Vehicle Report
Quantity
Price:
$14.00
Quantity
The rush fee is per MVR. We will return the Motor Vehicle Report the same day if we receive the request before 3pm.
Rush MVR Background Screening(s)
The rush fee is per MVR. We will return the Motor Vehicle Report the same day if we receive the request before 3pm.
Standard Drug Screen
Quantity
Price:
$39.00
Quantity
MRO Drug Screen for Modivcare
Quantity
Price:
$49.00
Quantity
DOT Drug Screen
Quantity
Price:
$59.00
Quantity
All Background Services with Standard Drug Screen
Quantity
Price:
$71.00
Quantity
All Background Services with MRO Drug Screen
Quantity
Price:
$81.00
Quantity
All Background Services with DOT Drug Screen
Quantity
Price:
$91.00
Quantity
Name of Person(s) the background is for
Additional Instructions or Comments
Background Services (Arkansas Only)
Arkansas Background Full Package
Quantity
Nationwide Criminal Report with Nationwide Sex Offender Search and Current Wants/Warrants Search
Arkansas Statewide Criminal Record
Motor Vehicle Record
Standard Drug Test
Price:
$83.00
Quantity
Arkansas Background Package (Excluding Drug Test)
Quantity
Nationwide Criminal Report with Nationwide Sex Offender Search and Current Wants/Warrants Search
Arkansas Statewide Criminal Record
Motor Vehicle Record
Price:
$44.00
Quantity
Background Services (Oklahoma Only)
Oklahoma Background Full Package
Quantity
Nationwide Criminal Report with Nationwide Sex Offender Search and Current Wants/Warrants Search
Arkansas Statewide Criminal Record
Motor Vehicle Record
Standard Drug Test
Price:
$99.00
Quantity
Oklahoma Background Package (Excluding Drug Test)
Quantity
Nationwide Criminal Report with Nationwide Sex Offender Search and Current Wants/Warrants Search
Arkansas Statewide Criminal Record
Motor Vehicle Record
Price:
$60.00
Quantity
Background Services (Tennessee Only)
Tennessee Background Package
Quantity
Nationwide Criminal Report
Social Security Search
Tennessee Statewide Criminal Record
Motor Vehicle Record
National Sex Offender Registry Search
Tennessee Sex Offender Registry Search
Tennessee Sexual Abuse Registry Search
Family Watchdog Registry Search
Felony Offender Registry Search
Price:
$69.50
Quantity
Tennessee Drug Test
Quantity
Dot Look-Alike with MRO Signature
Price:
$51.50
Quantity
Tennessee Alcohol Test
Quantity
DOT Alcohol test (Breathalyzer)
Price:
$51.00
Quantity
Background Services (Virginia Only)
Virginia Background Package
Quantity
Nationwide Criminal Report
Motor Vehicle Record
National Sex Offender Registry Search
Price:
$35.00
Quantity
Payment Info
Total Amount Due
If you purchased any background services and the total is not what you expected, please
review the quantity of each background service purchased
.
Consent
*
I agree that all sales are final and D. Lawson & Associates does not issue refunds for any of our services.
Email
This field is for validation purposes and should be left unchanged.