Agency Enrollment Form
Form must be returned as a signed original for enrollment approval to: GAPS Enrollment c/o Cogent Systems 5450 Frantz Rd, Suite #250 Dublin, OH 43016 888-439-2512 fax 614-718-9694				· Please use BLOCK letters and complete all fields · You must also complete the Georgia Bureau of Investigation’s Service Agreement (see Step 1 of the Agency Enrollment link at http://www.ga.cogentid.com )
Agency Details (Mandatory)
Agency Name
OAC/ORI Number
EIN Number
Agency Contact (Mandatory)			This information is known to be different from the information on file with GBI
Address
City			State					Zip Code
Contact Name
Contact Telephone
Contact Fax
Contact Email
Agency Enrollment - Standard		This is the default selection. Your agency will receive via email: · AGENCY LOGIN & PASSWORD. This will provide your agency access to general query and reporting functionality such as “who” and “when” an applicant has been fingerprinted for your agency. · VIEW RESULTS LOGIN & PASSWORD. This will provide your agency access to applicant results only if your agency is entitled to the results by federal and/or state law. Agencies that possess an ORI number (GAxxxxxZ) are entitled to review federal and state background check results. Agencies that possess an OAC number (GAPxxxxx) are entitled to review state background check results only.
Agency Enrollment – Billing		Your agency will receive via email: · AGENCY LOGIN & PASSWORD. This will provide your agency access to general query and reporting functionality such as “who” and “when” an applicant has been fingerprinted for your agency. · VIEW RESULTS LOGIN & PASSWORD. This will provide your agency access to applicant results only if your agency is entitled to the results by federal and/or state law. Agencies that possess an ORI number (GAxxxxxZ) are entitled to review federal and state background check results. Agencies that possess an OAC number (GAPxxxxx) are entitled to review state background check results only. · BILLING CODE & PASSWORD. The will provide your agency the ability, during applicant registration, to have the transaction billed to your agency’s account. Invoices for background check transactions are processed monthly.
Signature					Date
Cogent Authorization – to be completed by Cogent Systems after Agency has completed and returned the signature pages of GBI’s Applicant Services Package. Agency will be established by Cogent in GAPS System and USER ID & PASSWORD will be issued to the above noted contact.
Cogent Representative
Agency User ID						User ID and Password forwarded to Agency Contact via email on:
Agency Password							Date