Applicant's Information

"The applicant is considered to be the person who needs to be fingerprinted.

Name: *

First

Last

Date of Birth: *

Social Security Number: *

Type of photo ID: *

We kindly request that you bring the same valid ID to your Livescan fingerprint appointment as indicated on this online form. Please note that if you do not have it with you, we will need to cancel your appointment, and regrettably, we cannot offer refunds in such situations. Thank you for your understanding!

ID Number: *

Home Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone: *

Email: *

Complete this portion only if an FBI background check is needed:

Sex:

Race:

Height:

Weight:

Hair:

Eyes:

Reason for background check (be specific): *

Ohio Revised Code (Reason Code) for BCI background check:

If there is no ORC or reason code available, please indicate "NO ORC."

Ohio Revised Code (Reason Code) for FBI background check:

Where should the results of this background check be sent?

Direct copy options

Ohio Department of Education
Private Investigator Security Guard Services (PISGS)
BMV Dealer Licensing
Ohio State Racing Commission
OPOTA
Ohio Board of Pharmacy
Ohio Department of Commerce - MMCP
Ohio Veterinary Medical Licensing Board
Ohio Board of Nursing
Ohio Department of Liquor Control
BMV Deputy Registrar
Ohio Department of Insurance
Ohio Department of Agriculture - Hemp
Lottery Commission
Ohio Division of Real Estate & Professional Licensing
Ohio Medical Board
Ohio Construction Board
Ohio OT/PT/AT/Board
State Vision Professionals Board
Social Work Board
Child Care Center - Type A ODJFS
State Speech & Hearing Professionals Board
None

If Direct Copy option "NONE" was chosen above, or if the Direct Copy option chosen allows for a secondary copy, enter the mailing address below:

Agency Name:

Attention:

First

Last

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Waiver Information

I certify that the personal identifers provided on this form are accurate an I voluntarily and knowingly authorize the Ohio Bureau of Criminal Investigation (BCI) to conduct a criminal records check for information relating to me. I also voluntarily and knowingly authorize BCI to disseminate criminal arrest, conviction and juvenile delinquency adjudication records to: *

Applicant's name: *

First

Last

Applicant's Signature: *

Clear Signature

Date: *

Parent/Guardian name (minor applicants only):

First

Last

Parent/Guardian Signature:

Clear Signature

Date:

Please Read and sign below

I voluntarily and knowingly release and discharge the Ohio Attorney General's Office, BCI, Ohio Security & Investigations LLC, 10-8 Protective Services LLC, and their employees from all claims and liability related to this authorized criminal record review and dissemination. This authorization and waiver is valid for one year following the signature date below. *

Clear Signature

I have reviewed the information entered on this form, and I acknowledge that all information provided is accurate, I also understand that any mistakes or errors on this form are my responsibility. *

Clear Signature

I have reviewed the information entered on the WebCheck Screen, and I verify that all of the information is accurate. *

Clear Signature

I have reviewed the FBI Noncriminal Justice Applicant's Privacy Rights letter. *

Clear Signature

I was offered a copy of the Privacy Rights Letter and: *

Declined it.
Took it with me.
Requested that it be sent to me at the email address provided on this form.