ACCURATE BACKGROUND CHECK FINGERPRINT FORM

Please complete form entirely (any text box left blank will cause a delay in scheduling)

Name of Organization / Company / School / Requesting Court *
ORI# *

(We cannot schedule your background check without ORI)
OCA:

(Regulatory Agency DCF / APD / DJJ)
Name Name * First Middle Last
If you have a suffix, enter it after your last name.
ALIASES:

IF BACKGROUND CHECK IS FOR NAME CHANGE, PLEASE ENTER YOUR NEW NAME FOLLOWED BY ANY OTHER PREVIOUS LEGAL NAMES

(*Please separate all names with a comma.*)
Home Address: *
D.O.B D.O.B * / MM / DD YYYY
State & Country of Birth *
Gender (FBI options are Male or Female only at this time) *
Race/Ethnicity *
Eye Color *
Hair Color *
Height *

Example: 6' 2"
Weight *
Contact Phone# Contact Phone# * - ### - ### ####
Email *
Confirm *

Confirm I hereby certify that the information contained herein is true and accurate to the best of my knowledge.
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Payment

Payment $75 Education (College Admission / Clinicals) $98 Employment (Medical / DCF / Licensing) TEST 0.01
Form ID
Type the letters you see in the image below.