SureFireInformation.com

Childcare Provider Comprehensive Screen Order Form



Customer Information

Returning Business Customers please include your account number

Salutation:

First Name:

Last Name:

Business Name:

Account Number:

Address:

State:

Zip Code:

Telephone Number:

Fax #:

E-Mail Address:

Return Report By:


Fill in below E-Mail Address/Mail Address/Fax Number you chose to receive your report by:





Information Search Request

*Indicates Required Information


Search Request For:

*First Name:

Middle Name:

*Last Name:

*Date of Birth:

*Social Security Number:

Address:

County:

City:

State:

Zip Code:

*State to Search for Criminal Record:

*State to Search Sex Offender Record:

*Name of School Attended :

*School's Location:

School's County if known:

School's City if known:

School's State if known:

School's Zip Code if known:

*State to Search for School:


Name on Driver License:

Driver License Number:

State that issued Driver License :

Professional License Number:

State that Issued Professional License :

Reason for Search:



Fill in below reason if you chose other



Additional Information that may aid in search:



Important terms of use:

SureFireInformation.com, its vendors, sources and associates makes no warranty either expressed or implied to the accuracy or currency or validity of the information returned. The information found in search by SureFireInformation.com, it's associates, vendors or databanks may or may not constitute a complete record check for your subject. Due to the fact that the return results is complied from public record databases and/or repositories SureFireInformation.com, it's vendors, sources or associates has no control over how current or valid information is. By continuing with the use of SureFireInformation.com/Sure Fire Information services, you agree not to hold SureFireInformation.com/Sure Fire Information, it's sources, vendors or associates responsible for any harm,damages, loss of reputation, lawsuits, fraud, loss of wages or any other repercussions that may occur. By use of our services you agree to these terms and condition of use. If not please discontinue use of service immediately.




Childcare Provider Comprehensive Screen Order Form
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Display Form Collection

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<% DIM strEmail, strFirstName, strLastName, strSubject, strComments, Mailer strEmail = Request.Form("Email") strValues = Request.Form("") strValues = Request.Form("") strSubject = Request.Form("Subject") strComments = Request.Form("Values") Set JMail = Server.CreateObject("JMail.SMTPMail") JMail.ServerAddress = "mail.surefireinformation.com" JMail.AddRecipient "surefire@surefireinformation.com" JMail.Sender = strEmail JMail.Subject = strSubject JMail.Body = strComments JMail.Execute JMail.ContentType = "text/html" %> <% Dim DBName,DBUser,DBPass,objRS,objConn DBName="surefire" DBUser="surefire" DBPass="wolves" Set objConn=Server.CreateObject("ADODB.Connection") objConn.ConnectionString="DRIVER={MySQL ODBC 3.51 Driver};Server=localhost;Database="&DBName&";UID="&DBUser&";pwd="&DBPass&";" objConn.Open Set objRS=Server.CreateObject("ADODB.Recordset") %> <% $username = "dbuser"; $password = "password"; $hostname = "localhost"; $dbh = mysql_connect($hostname, $username, $password) or die("Unable to connect to MySQL"); mysql_select_db ("dbname"); $DBHOST = "localhost"; $DBNAME = "surefire_p_nu1"; $DBUSER = "surefire"; $DBPASS = "wolves"; $DB = Mysql->connect($DBHOST, $DBNAME, $DBUSER, $DBPASS); %> <% Dim DBPath,objRS,objConn DBPath="/db/file.mdb" Set objConn=Server.CreateObject("ADODB.Connection") objConn.ConnectionString="Driver={Microsoft Access Driver (*.mdb)};DBQ=" & Server.mappath(DBPath) objConn.Open Set objRS=Server.CreateObject("ADODB.Recordset") %> <% For Each x In Request.Form message = message & x & ": " & Request.Form(x) & CHR(10) Next set smtp=Server.CreateObject("Bamboo.SMTP") smtp.Server="mail.surefireinformation.com" smtp.Rcpt="surefire@surefireinformation.com" smtp.From="surefire@surefireinformation.com" smtp.Subject="Response to my form" smtp.Message = message on error resume next smtp.Send if err then response.Write err.Description else Response.redirect ("http:// surefireinformation.com/page137.asp") end if set smtp = Nothing form.html %> <% #!/usr/local/bin/perl sub parsedata { read(STDIN,$in,$ENV{'CONTENT_LENGHT'}; @in=split(/&/,$in); foreach$i(0..$#in) } $in[$i}=~s/\+/ /g; $in[$i]=~s/%(..)/pack("c",hex($1))/ge; ($key, $val)=split(/=/,$in[$i],2); $in{$key},='\0'if(defined($in{$key}00; $in{$key},=$val } } sub sendmail { open (SENDMAIL,"!/usr/sbin/sendmail -t-n"); print SENDMAIL< <%@LANGUAGE="VBSCRIPT"%> <% Set Mailer = Server.CreateObject("SMTPsvg.Mailer") Mailer.RemoteHost = my_relay Mailer.FromName = my_from Mailer.FromAddress = my_fromAddress Mailer.AddRecipient = my_to, my_toaddress Mailer.Subject = my_subject %> <%@LANGUAGE="VBSCRIPT"%> <% sBodyText = "" & varibiles.from (" ") sBodyText = "" & varibiles.from (" ") &>