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STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY
LIVESCAN PRE-REGISTRATION APPLICATION
APPLICANT INFORMATION
(PLEASE TYPE OR PRINT CLEARLY)
Name:
*
Date of Birth:
*
SSN:
*
Gender:
*
Male
Female
Height:
ft.
inches
Weight:
lbs.
Eye Color:
Hair Color:
Race:
*
Black or African American
White
Hispanic or Latino
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Two or more races
Other
Place of Birth:
Citizenship:
Current address:
*
City:
*
State:
*
ZIP Code:
*
Daytime Phone:
Evening Phone:
Driver’s License #:
*
AGENCY INFORMATION
Agency Authorization #:
*
ORI # (if required):
What is the reason you were fingerprinted?
*
Position Applied for:
*
Request Type:
(Only choose
one
)
*
Adult Dependent Care
Attorney/Client
Minor Care
Criminal Justice
Gold Seal/Adoption
Gold Seal/Letter/VISA
Government Employment
Government Licensing or Certification
Immigration/VISA
Individual Challenge
Individual Review
MSP Licensing
Private Party Petition
Public Housing
REQUIRED INFORMATION
Please answer Yes or No:
Have you ever been charged or convicted of any criminal activity?
*
Do you have any pending criminal charges?
*
Mail Response To
(Mailing option only available for Visa Gold Seal and/or Individual Review)
Name:
Address:
City:
State:
ZIP Code: