Background Check Livescan Form

BACKGROUND CHECK LIVESCAN FORM

Provider Name:    Provider ORI/ID:

RECITALS

WHEREAS, Provider Name: operates a licensed live scan fingerprinting service and is authorized to transmit electronic fingerprints to criminal history repositories for background check purposes;

WHEREAS, Applicant Name: requests a state and/or national fingerprint-based background check and consents to the submission of fingerprints for the purpose stated in this form;

WHEREAS, the parties desire to document the scope, consent, fees, confidentiality, and legal terms governing the live scan submission and any resulting background report.

APPLICANT INFORMATION

Date of Birth:    Place of Birth:

Sex:    Race/Ethnicity:    Height:

Weight:    Eye Color:    Hair Color:

Phone:    Email:

REQUESTING AGENCY / PURPOSE

Agency ORI or Code:

Employment    Licensing    Volunteer    Immigration    Certification    Other:

SCOPE OF BACKGROUND CHECK

PAYMENT TERMS

Fee Amount: $    Payment Due:

Cash    Check    Credit / Debit Card    Bill Agency

Late Fee:    Collection Costs: Applicant is responsible for reasonable collection costs and attorney fees for overdue amounts: Acknowledged

TERM AND TERMINATION

Service Start Date:    Service End Date / Record Retention:

Either party may terminate this submission process for cause upon written notice. Provider may retain and transmit fingerprint images and any report generated during the retention period required by law or agency policy and may charge outstanding fees incurred through the date of termination.

CONFIDENTIALITY

Provider will maintain confidentiality of personally identifying information and fingerprint images except as necessary to submit fingerprints to public criminal history repositories, to comply with legal process, or to provide results to the requesting agency. Provider will implement commercially reasonable administrative, technical, and physical safeguards to protect applicant data.

CONSENT, AUTHORIZATION, AND CERTIFICATION

By signing below, Applicant affirms that the foregoing information is true and complete, authorizes Provider to capture and transmit fingerprints to state and federal criminal history repositories and to release results to the requesting agency specified herein. Applicant consents to the use of this information for employment, licensing, certification, or other lawful purposes indicated. Applicant understands that results may include state and national criminal history information and that Provider and the requesting agency are not responsible for any decisions made on the basis of those results.

Applicant expressly releases Provider from liability for proper submission and transmission of fingerprint data, except for willful misconduct or gross negligence. Applicant understands the right to challenge inaccurate records through the appropriate repository and acknowledges that Provider is not the entity responsible for adjudication of criminal history.

GOVERNING LAW; ENTIRE AGREEMENT

This form and any dispute arising out of the fingerprint submission or the interpretation of its terms shall be governed by the substantive laws of the state in which the Provider operates, without regard to that state's conflict of laws principles. This document constitutes the entire agreement between the Provider and Applicant regarding the live scan submission and supersedes any prior oral or written statements or agreements.

NOTICE AND CONTACT

For billing, scheduling, or questions about this submission contact Provider Name: Phone:

APPLICANT ACKNOWLEDGMENTS

I acknowledge receipt of a copy of this Background Check Livescan Form, understand the purpose and scope of the fingerprint submission, and agree to the terms set forth above.

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