The Work Number | Universal Membership Agreement

APPLICATION /MEMBERSHIP AGREEMENT
for

The Work Number^® eCommerce Services

Important : Please fill out the form below, click on "Continue" and fax the printed copy to E-Commerce Services at 314-812-6850.

Pricing Information

Monthly Payment by Check or Credit Card

Annual Fee :

No annual fee

Employment Verifications:

$12.30 each

Income Verifications:

$15.30 each

•	If payment is made by credit card, TALX will charge the credit card each month for the transactions completed in the prior month.
•	Invoices are due net 30days with 1.5% interest per month applied over 45 days. Invoices past 45 days will result in loss of access to Service

* Required Fields

Organization Information

Please enter your company's name.

*Company Name:

Web address:

Stock Symbol:

DUNS #:

Please enter your state of incorporation/Organization.

*State of Incorporation/
Organization:

Professional Affiliation:

Please select your industry.

*Industry:

	Mortgage		Consumer Credit		Pre-Employment		Other
	Property Management		Collections		Background Investigation

Please estimate the number of verifications you will perform each month.

* How many verifications will you perform per month?

Please enter the intended purpose for your verifications.

Please limit your response to 1,000 characters.

Please remove specials characters from your response.

* Intended Purpose:

Main Contact Information

Please enter the name of the main contact for this service.

*Name:

Please enter your title.

*Title:

Please enter your phone number.

*Phone:

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Please enter your fax number.

*Fax:

Please enter your primary e-mail address.

*Primary Email:

Please enter your address.

*Address:

(No PO Box)

Please enter your city.

*City:

Please select your state.

*State:

Specify other:

Please enter your zip code.

*Zip:

Please enter your supervisor's name.

*Supervisor Name:

Please enter your supervisor's phone number.

*Supervisor Phone:

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Billing Information

Please enter the name of the billing contact.

*Billing Contact:

Please enter your billing phone number.

*Billing Phone:

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Please enter your billing fax number.

*Billing Fax:

Please enter your billing e-mail address.

*Billing Email:

Please enter billing address if different than above.

Address:

(No PO Box)

City:

State:

Specify other:

Zip:

Please select your method of payment.

*Payment Method:

Check

Credit Card

Your Invoice/Detailed Transaction Report will be sent by Email.

Credit Card Information

Please select your credit card type.

Credit Card Type:

American Express

Visa

MasterCard

Discover

Please enter your credit card account number.

Credit Card Account Number:

Please enter your cardholder's name.

Cardholder's Name:

Please enter your card's expiration date.

Expiration Date:

Credit Reporting Compliance

Please enter the name of the compliance contact.

*Compliance contact:

(Either Compliance Officer or person responsible for credit reporting compliance)

Please enter the title of the compliance contact.

*Title:

Please enter the email address for the compliance contact.

* Email Address:

Please enter the compliance contact's phone number.

*Contact Telephone:

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Please enter your compliance contact's fax number.

*Fax:

Business Credit References

Please enter 2 credit references.

1)*Name of Creditor:

*Contact Telephone:

ext

*Account Number:

2)* Name of Creditor:

*Contact Telephone:

ext

*Account Number:

Additional User Information

We ask that you do not share usernames or passwords.

Please provide the names and e-mail addresses of up to 5 additional users. Please note: The "Main Contact" above will have the ability to add users via the webManager function. What is webManager?

Name

E-mail Address

User 1:

Please enter your cardholder's name.

User 2:

Please enter your card's expiration date.

User 3:

User 4:

User 5:

Completion and submission of this
application in no way guarantee service.