Place Your Order - Viewpoint Screening

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Required Package
The Electrocardiograph Technician program at Fletcher Technical Community College requires the following services to be performed.
Background Check:	County Criminal Records (all jurisdictions within the past 1 year) Nationwide Crime Database Sexual Offender Registry Healthcare Fraud & Abuse Scan (OIG/GSA) Address History / SSN Validation
Price:	$30.00

I have read, understand and agree to the Viewpoint Screening Disclaimer and Refund Policy.

Applicant Information
Do not place an order on someone's behalf. This form must be filled out by the individual who requires Viewpoint Screening services.
First Name^*:
Last Name^*:
Middle Name:
Alias/Maiden Name 1:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 2:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 3:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Social Security Number^*:	- - Please Note: If you have not been issued a valid U.S. SSN then enter all zeros (000-00-0000) instead.
Date of Birth^*:	/ / (mm/dd/yyyy)
Gender^*:	Male Female
Phone Number^*:	(111-111-1111)
Student ID^*:
E-Mail Address*:	IMPORTANT Your email address will be your user name to log in. If you have placed a previous order, it is recommended to use the same email address to prevent separate logins. Separate logins will contain separate results / medical documents, and cannot be combined. Please make sure you are entering your correct email address. You will be unable to log in or receive communications from Viewpoint Screening if your email address is not valid. Type E-mail address. Re-type E-mail address. Please make sure you are entering your correct email address. You will be unable to log in or receive communications from Viewpoint Screening if your email address is not valid.

Current Residential Address:
Address^*:
City^*:
State or U.S. Territory^*:	For an international address, select "International" and select the foreign Country name below.
Country^*:
Zip Code^*:	ZIP Code Look Up Tool Please Note: If you have an international address that does not require a Zip Code, please fill in "00000".

Payment Information

First Name^*:
Last Name^*:
Credit Card Number^*:
Exp. Date^*:	(MM/20YY)
CVV^* ?
Credit Card Type^*:
Contact Name (if business):
Email^*:
Phone Number^*:
Address^*:
City^*:
State^*:
Postal Code^*:
IMPORTANT: Please note that if you enter an address other than the one on file with the credit card's issuing bank, or an incorrect CVV code, Viewpoint Screening will deny your transaction for security purposes. Additionally, denied transactions may cause the funds to be held by your bank for up to 5 business days before being released back to the card. "Viewpoint LLC" will appear on your credit card statement. A Parent or Guardian's credit card will be accepted. They should be made aware of this transaction. WARNING: Your credit card will be charged $ 30.00 when you click "Next." This fee is non-refundable under any circumstances. Do not click more than once or you may be charged multiple times.

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