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)

Needed for Department Children and Families
Name Name * First Middle Last
IF NAME 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 Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
SSN *

e.g. "555442222"
D.O.B D.O.B * / MM / DD YYYY
Place of Birth (State in USA or Country) *
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 *
Available Days *

Available Days Monday Tuesday Wednesday Thursday Friday Anytime
From: (Time) From: (Time) * : HH MM AM/PM
To: (Time) To: (Time) * : HH MM AM/PM
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.