INFORMATION FORM REQUEST 1 REGULATING AGENCY SECTION2 NAME3 DEMOGRAPHICS4 NATIONALITY AND CITIZENSHIP5 CONTACT INFORMATION6 EMPLOYMENT INFORMATIION7 IDENTIFICATION8 SIGNING REGULATING AGENCY SECTIONJob or License Type*Select Provider Type*Certified Nursing AssistantAcupunctureAHCA GeneralAlachua CountyAlcohol, Beverages &TobaccoAnesthesiologist AssistantAPD CDCAPD GeneralAthlete AgentsAthletic TrainingBrevard CountyChiropractic PhysicianClinical Lab PersonnelClinical Nurse SpecialistClinical Social Work, Marriage & Family, Mental Health CounselingCollection AgencyCommunity Association Managers (CAM)Construction & ContractorsDCF GeneralDCF Mental Health ProvidersDCF Summer Camp ProvidersDentistryDepartment of Elder AffairsDietetics/NutritionDJJ EmployeeDJJ VolunteerDOE Teacher CertificationDrugs, Devices & CosmeticsElectrolysisEmployee LeasingEscambia CountyFlorida Medicaid Providers and EnrolleesGuardianship (State-wide)Hearing Aid SpecialistHillsborough CountyHome InspectorsIndependent Living EmployeeIndependent Living VolunteerLake CountyManaged Care (All)Manatee CountyMassage TherapyMedical MarijuanaMedical PhysicistMiami-Dade CountyMidwiferyMold Remediation &AssessorMoney TransmitterMonroe CountyMortage Loan Originator (Individual MLO)Mortgage Broker & Lender (CONTROL PERSON)NaturopathNursing Home AdministratorOccupational TherapyOpticianryOptometryOrange CountyOrthotist & ProsthetistOsteopathic PhysicianPalm Beach CountyPalm Beach CountyPasco CountyPharmacistPhysical TherapyPhysician AssistantPhysician/Medical Doctor (General MD)Pinellas CountyPodiatric PhysicianPrivate Investigative, Private Security and Repossession ServicesPsychologyReal Estate AppraisersReal Estate Sales Associates & BrokersRegistered Nurse (RN) / Licensed Practice Nurse (LPN) / Advanced Practice Registered Nurse (APRN)Respiratory CareSarasota CountySchool PsychologySecond Hand Dealer LicenseSecurities / Investment AdvisorsSpeech/Language PathologyTalent AgentsTemp License For Military SpouseTruck Driving School or Third Party ProviderVehicle Dealer & Manufacturer OwnerVendor Registration EmployeeVendor Registration VolunteerVolunteer & Employee Criminal History System VECHSORI Number*VECHS NumberAgencyScreening Request IDOCA or DOE NumberClearinghouse PhotoI will be emailing my Clearinghouse photoI will not be emailing my Clearinghouse photoFor 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: NAMEName of Applicant:* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Aliases/Prior Married NamesFirstMiddleLast APPLICANT SECTION: DEMOGRAPHICSDate of Birth* Date Format: YYYY slash MM slash DD Gender*MaleFemaleHeight*4 ft (or shorter)4 ft 1 in4 ft 2 in4 ft 3 in4 ft 4 in4 ft 5 in4 ft 6 in4 ft 7 in4 ft 8 in4 ft 9 in4 ft 10 in4 ft 11 in5 ft5 ft 1 in5 ft 2 in5 ft 3 in5 ft 4 in5 ft 5 in5 ft 6 in5 ft 7 in5 ft 8 in5 ft 9 in5 ft 10 in5 ft 11 in6 ft6 ft 1 in6 ft 2 in6 ft 3 in6 ft 4 in6 ft 5 in6 ft 6 in6 ft 7 in6 ft 8 in6 ft 9 in6 ft 10 in6 ft 11 in7 ft7 ft 1 in7 ft 2 in7 ft 3 in7 ft 4 in7 ft 5 in7 ft 6 in7 ft 7 in7 ft 8 in7 ft 9 in7 ft 10 in7 ft 11 in (or taller)Weight (lbs):*Eye Color*BlackBlueBrownGrayGreenHazelMaroonMulticoloredPinkUnknownSelect your natural eye colorHair Color*BaldBlackBlond or StrawberryBlueBrownGray or Partially GrayGreenOrangePinkPurpleRed or AuburnSandyWhiteSelect your natural hair color APPLICANT SECTION: NATIONALITY AND CITIZENSHIPCountry of Birth*United StatesCanadaMexicoAfghanistanAguascalientesAlbaniaAlgeriaAll othersAndorraAngolaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanAzores IslandsBahamasBahrainBalearic IslandsBangladeshBarbadosBelgiumBelizeBermudaBhutanBoliviaBosnia HercegovenaBotswanaBrazilBrazzavilleBritish Indian Ocean TerritoriesBritish Solomon IslandsBritish Virgin IslandsBruneiBulgariaBurmaBurundiBelarusCambodiaCameroonCampecheCanal ZoneCanary IslandsCape Verde IslandsCaroline IslandsCayman IslandsCentral African RepublicChadChileChinaColombiaCongoCosta RicaCroatiaCubaCyprusCzechoslovakiaDahomeyDenmarkDistrito FederalDominicaDominican RepublicDucie IslandsEast GermanyEcuadorEgyptEl SalvadorEnglandEquatorial GuineaEsthoniaEthiopiaFalkland IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgia (Country)GermanyGhanaGibraltarGilbert/Ellice IslandsGreeceGreenlandGrenadaGuatemalaGuineaGuinea/BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJohnston IslandsJordanKazakhstanKenyaKoreaKuwaitKyrgystanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadeira IslandsMalagasy RepublicMalawiMalaysiaMaldivesMaliMaltaManahiki IslandMariana IslandsMartiniqueMauritaniaMauritiusMicronesiaMidway IslandsMoldovaMonacoMongoliaMontanaMontenegroMontserratMoroccoMozambiqueNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew GuineaNew HebridesNew ZealandNicaraguaNigerNigeriaNorth KoreaNorth VietnamNorthern IrelandNorwayOkinawaOmanPakistanPanamaParaguayPeoples Republic of ChinaPeruPhilippinesPitcrn Hendrsn Ducie OenoPolandPortugalRepublic of YemenReunionRhodesiaRomania/RumaniaRussiaRussian FederationRwandaSaint HelenaSaint LuciaSaint Pierre/MiguelonSaint VincentSan MarinoSao Tomer/PrincipeSaudi ArabiaScotlandSenegalSerbiaSeychellesSierra LeoneSikkimSingaporeSloveniaSocialist Republic of YemenSomaliaSouth AfricaSouth KoreaSouth VietnamSouthern YemenSouthwest AfricaSoviet UnionSpainSpanish SaharaSri Lanka (Ceylon)St Kitts/Nevis/AnguillaSudanSurinamSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimorTogoTongaTongareva IslandTrinidad/TobagoTrucial StatesTuamotu ArchipelagoTunisiaTurkeyTurkmenistanTurks/Cacos IslandsUgandaUkraineUnited Arab RepublicUnknownUpper VoltaUruguayUzbekistanVenezuelaVietnamWake IslandWalesWest GermanyWest IndiesWestern SamoaYemenYugoslaviaZaireZambiaIf 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*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPuerto RicoUSVIPlace of Birth within Canada*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPlace of Birth within Mexico*AguascalientesBaja CaliforniaBaja California SurCampecheChiapasChihuahuaCoahuilaColimaDurangoGuanajuatoGuerreroHidalgoJaliscoMéxicoMichoacánMorelosNayaritNuevo LeónOaxacaPueblaQuerétaroQuintana RooSan Luis PotosíSinaloaSonoraTabascoTamaulipasTlaxcalaVeracruzYucatánZacatecasUnknown Mexican StateUS Citizen?*YesNoCountry of Citizenship*If dual citizen, but not with US, please type only one country.Race*Please select raceWhiteBlackAsian or Pacific IslanderAmerican Indian or Alaskan NativeUnknown/OtherSocial 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 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 INFORMATIONStreet 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 continueOccupation:Business Name:Address:City:State/Province:Zip/Postal: IDENTIFICATION:You will need to provide us with one clear, color copy of a primary and a 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 IDs Drop files here or Accepted file types: jpg, gif, png, pdf, jpeg. 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:*TitleCommentsThis field is for validation purposes and should be left unchanged.
