PALLTECH APPLICATION

NOTE TO THE APPLICANT: Applications typically take 24 to 72 hours to process. Upon verification of all of your input data and your completion of a DIOGENES User Agreement, a Pallorium representative will telephone you with passwords. All applications require the payment of a signup fee, which is refunded in full to the PallTech subscriber's account after one (1) year.

Please enter your FIRST AND MIDDLE NAME(S) here:    
Please enter your LAST NAME here:                   
Please enter your COMPANY NAME here:                
Please enter your STREET ADDRESS here:              
Please enter your CITY here:                        
Please enter your STATE (or PROVINCE) here:         
Please enter your ZIP (POSTAL) CODE here:           
Please enter your DATE OF BIRTH (MM/DD/YY)here:     
Please enter your BUSINESS TELEPHONE here:          
Please enter your RESIDENCE TELEPHONE here:         
Please enter your ELECTRONIC MAIL ADDRESS here:     
Please enter THE BEST TIME TO CONTACT YOU here:     
Please enter your INVESTIGATIVE AGENCY LICENSE NO.: 
Please enter the STATE in which you are licensed:   
Please enter DATE your license expires (MM/DD/YY):  

What is the estimated number of persons employed by your 
company who will be accessing the DIOGENES online service? 

Please enter the estimated number here:      


Are you a member of any investigative or professional associations
(ie. WAD, CII, ACFE, NAIS, NALI, ION)? 

Please enter the association's name(s) here: 


Access to DIOGENES provides the user with the ability to  obtain information on 
individuals and companies which may be both sensitive and confidential. In order
to properly and responsibly screen your application, we will be obtaining a copy
 of your consumer credit report.Do we have your permission to obtain this report? 

Please enter YES or NO here:                


In connection with this application, do you have any questions or comments,  or 
is there any information which you feel that we should know prior to processing
your application? If so, please enter your comments in the space provided below.