C & B Background Fingerprinting & Services, LLC
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PO Box 2371 - Okeechobee, FL 34973 Office - (863) 763-2300 Fax - (863) 763-4846
____________________________________________________________________________________________
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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