Live Scan Application Form | ALTA Healthcare Services

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:*

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:

STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY

LIVESCAN PRE-REGISTRATION APPLICATION

STATE OF MARYLAND DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY

LIVESCAN PRE-REGISTRATION APPLICATION

STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY