Intake Form

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Intake Form

This form allows us to search Michigan criminal records for any convictions associated with your name that have not been set aside. Please fill out the form to the best of your ability. If you don't know all the information off the top of your head, don't worry about it. Just tell us what you know, and we'll do the rest.

This form must be filled out by the subject of the assessment. If you purchased a Clean Slate Check as a gift, please direct the gift recipient to this page to complete.

First Name *

Middle Name *

Last Name *

Any aliases/alternate name spellings you would like us to search *

Date of Birth *

Current Street Address *

Current City of Residence *

Phone Number *

Email Address Where You Would Like To Receive Your Report *

How do you want us to contact you if we have questions during our investigation? *

Text Message, at the phone number provided above
Email, at the email address provided above

Year(s) of Conviction(s), If Known

County/Counties Where Convicted *

Gender at Time of Conviction(s) *

Male
Female
Other

Race (To search Michigan's criminal history repository, we must select one of the following. Please indicate which choice you believe would be been selected by the police when you were arrested). *

American Indian or Native Alaskan
Asian or Pacific Islander
Black
Unknown/Other
White

Any additional information you would like us to have while conducting our investigation?

Invoice Number (included in the invoice attached to the confirmation email received after checkout) *

Leave this field empty

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