C & B Background Fingerprinting & Services, LLC



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PO Box 2371 - Okeechobee, FL 34973 Office - (863) 763-2300 Fax - (863) 763-4846

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AGENCY INFORMATION

Agency’s Name: _______________

Owner: ___________

Manager / Director/Contact: _____

Address:

City: State: Florida Zip Code:

Telephone: Fax. Number:

Alt. Phone Number:

Email Address:

ORI # OCA #

(Begins with FL) (9 Character)

Credit Card Information:

Type of Card: (Select One) Visa Master Card Discover

Sorry We Do Not Accept American Express

Name on Card: __________________

Number on Card: Exp Date:

Security Code (CVV): Zip Code: _____

Please complete the above information and return to C&B Background Fingerprinting & Services Fax number. 863-763-4846.

Thank You,

John R. Creasman

Owner

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