EXHIBIT 10.1.2
Avert, Inc.
000 Xxxxxxxxx Xxxxxx
Xxxx Xxxxxxx, XX 00000
000-000-0000
Consumer Report User Agreement
Please read and complete this agreement and fax to Avert. Payment of the $50.00
set up fee is accepted by check or credit card. You will be billed net 30 days
for Avert products and services. When your account is established, we will call
you with your customer number and send you a copy of this agreement. The
security and dissemination of this unique customer number is the responsibility
of the person signing this agreement. Avert will neither release information nor
take orders for services unless the customer number is provided. If you are
dissatisfied for any reason, notify Avert in writing within 30 days of the date
you signed this agreement. Your account will be closed and your set up fee (less
charges for products and services ordered) will be refunded.
YOUR CUSTOMER NUMBER IS
DELIVERY ADDRESS FOR REPORTS (One address must be the physical location of your
company)
Business Name (User)____________________________________________________________
Address ________________________________________________________________________
Phone # _____________________________________ Fax #_____________________________
Email Address___________________________________________________________________
Contact(s)______________________________ Second_________________________________
BILLING ADDRESS (Invoices to be sent here)
Business Name (User)____________________________________________________________
Address ________________________________________________________________________
Phone # _____________________________________ Fax #_____________________________
Email Address___________________________________________________________________
Contact(s)______________________________ Second_________________________________
First Last Title First Last Title
BILLADDRESS Invoices to be sent here.
1. Please describe your company' s business.___________________________________
________________________________________________________________________________
2. List approximate number of employees._______________________________________
3. How long has your company been in business?_________________________________
4. Is your company in a: ( ) Commercial ( ) Industrial ( ) Residential
( ) Other (please explain) _________________________________________________
________________________________________________________________________________
5. If you intend to use Name Link, Instant Address Link and/or Credit Link (for
employment purposes only) please provide a copy of ONE of the following items
listed below:
( ) Your business license ( ) Federal/StateTax ID Form (Government Issued)
( ) Articles of Incorporation ( ) Sales Tax License
6. Identify two principals (or owners) of your business, or if your company
stock is traded on a recognized stock exchange, please provide the symbol and
exchange.
-------------------------- -------------------------------------- ------------
Name Title Phone
-------------------------- -------------------------------------- ------------
Name Title Phone
-------------------------- -----------------------------------
Symbol Exchange
7. Basic Account ( ) AVERTadvantage for $10/month ( ) AVERTadvantage Plus for
$20/month ( )
8. If paying $50 set up fee by credit card, please complete the following:
(Visa, Mastercard and American Express accepted)
User certifies that the "Terms for Consumer Report User Agreement" have been
read and agrees to the terms as written.
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User Authorized Signature Title Date
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Avert, Inc. Authorized Signature Title Date
EMPLOYMENTUA98.10
