Place Your Order - Viewpoint Screening

Required Package
The Dental Hygiene program at Waukesha County Technical College requires the following recheck to be performed.
Background Check:	Wisconsin DOJ & DHFS Caregiver Background Check Wisconsin Circuit Court Statewide Criminal Records Address History / SSN Validation
Price:	$25.00

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

Upload Release Form

In order to obtain Wisconsin background check information, it is required that *this form* be:

PRINTED (print this form off)

FILLED OUT (fill the form out completely)

UPLOAD (upload this form back onto site)

You cannot/will not be able to proceed with your order until this form has been completed and uploaded here.

* All 4 pages must be provided. *
If all 4 pages are not provided or filled out correctly, your Wisconsin background check will be cancelled and you will be required to place a new Wisconsin order at the cost of $5.00.

Use this link to combine PDF files
OR
use this link to combine image files into a PDF file.

Please make sure that you have signed and dated this document.

Applicant Information
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)
E-Mail Address*: ^{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".

First Name^*:
Last Name^*:
Credit Card Number^*:
Exp. Date^*:	(MM/YYYY)
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. WARNING: A non-refundable fee to place this order will be charged to your credit card once you click "Next."

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