SIGNUP FOR PALLTECH / DIOGENES

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.

(TO APPLY IMMEDIATELY, PLEASE ANSWER THE FOLLOWING QUESTIONS.)

(PLEASE COMPLETE THE FOLLOWING APPLICATION IN ITS ENTIRETY.)

Please enter your FIRST AND MIDDLE NAME(S):

Please enter your LAST NAME:

Please enter your COMPANY NAME:

Please enter your STREET ADDRESS:

Please enter your CITY:

Please enter your STATE (or PROVINCE):

Please enter your ZIP (POSTAL) CODE:

Please enter your DATE OF BIRTH (MM/DD/YYYY):

Please enter your BUSINESS TELEPHONE:

Please enter your RESIDENCE TELEPHONE:

Please enter your MOBILE TELEPHONE:

Please enter your EMAIL ADDRESS:

Please enter THE BEST TIME TO CONTACT YOU:

Please enter your INVESTIGATIVE AGENCY LICENSE NUMBER:

Please enter the STATE in which you are licensed:

Please enter the DATE your license expires (MM/DD/YYYY):

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

Please enter the estimated number:

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

Please enter the association name(s):

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:

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.

(Please note that additional information may be required to complete this application.)

FOR MORE INFORMATION ABOUT OUR PRODUCTS AND SERVICES, OR FOR A SPECIAL INVESTIGATIVE REQUEST, PLEASE CONTACT US VIA EMAIL OR BY TELEPHONE OR FAX.

P. O. Box 155 - Midwood Station - Brooklyn, New York 11230 USA

Telephone: (001) 212-969-0286 - Telecopier: (001) 212-858-5720

Electronic Mail : pallorium@pallorium.com

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PallTech Application