Information Request Form

1REGULATING AGENCY SECTION

2NAME

3DEMOGRAPHICS

4NATIONALITY AND CITIZENSHIP

5CONTACT INFORMATION

6EMPLOYMENT INFORMATIION

7IDENTIFICATION

8SIGNING

REGULATING AGENCY SECTION
Job or License Type*
ORI Number*
VECHS Number
Screening Request ID
OCA or DOE Number
Clearinghouse Photo*
- I will send my REQUIRED Clearinghouse photo via email
For employment or licensing in the healthcare, mental health, juvenile justice, or child care fields in Florida only. More information in the link below: For Andriod Users: https://www.youtube.com/watch?v=pXPLSN9euPk For iPhone Users: https://www.youtube.com/watch?v=HCyjtJ834tM

APPLICANT SECTION: NATIONALITY AND CITIZENSHIP
Country of Birth*
If you were born in the UK, try searching for the constituent country. For example, if you were born in England, then you will select England.
Place of Birth within USA*
Select N/A if you were not born in the US
US Citizen?*
- Yes
- No
Country of Citizenship*
If dual citizen, but not with US, please type only one country.
Race*
Social Security Number*
Most criminal history record checks require a social security number or ITIN to process. While it is not required now, you must ensure that if you have been issued a SSN or ITIN that you provide this number in the appropriate field labeled "SOCIAL SECURITY NO. SOC" on the FD-258 fingerprint card in order to process the background check.
- I acknowledge that if it is required, I will provide a correct and matching social security number or ITIN at the time of fingerprinting.

APPLICANT SECTION: CONTACT INFORMATION
Street Address:*
Required for any correspondence that will be sent to you in the two weeks following your fingerprints.
Unit #:
City:*
State/Province:*
Country*
Zip/Postal:*

Employment Information:
This information is unnecessary for your application. Please click "Next" below to continue
Occupation:
Business Name:
Address:
City:
State/Province:
Zip/Postal:

IDENTIFICATION:
You will need to provide us with one clear color copy of a primary and one copy of your secondary ID for the applicant. If available, you may upload these files now using the attachment below. What qualifies? Primary IDs must be government-issued photo ID such as:
- Driver’s License
- Passport
- State ID
- Concealed Weapons Permit, or
- Permanent Resident Card
Secondary ID may be any of the IDs listed above, but if not available, it must be an ID which has at least the applicant’s name on it (need not be government-issued) such as:
- Birth Certificate
- Marriage Certificate
- Social Security Card
- Voter Registration Card
- Bank or credit card (with the numbers obscured)
NOTE: Too dark, grainy, or faint copies are not acceptable. If you are not sure if your identification qualifies, please call and check with one of our representatives before uploading/sending. Your request will NOT be processed without proper identification.
Upload Primary ID*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.
MAX SIZE for each file is 7MB
Upload Secondary ID*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.
MAX SIZE for each file is 7MB

SIGNING:
I hereby certify that the information indicated on this form is true and accurate and that I am authorized to execute this form.
*
- I have read and fully understand the PRIVACY STATEMENT , DATA COLLECTION POLICY , and TERMS AND CONDITIONS
Type Name of Individual Signing Here:*
Title
Name
This field is for validation purposes and should be left unchanged.

REGULATING AGENCY SECTION

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