Fingerprint Authorization Form

FINGERPRINT AUTHORIZATION FORM

Parties

Client Name:

Service Provider:

Recitals

WHEREAS, Client requires fingerprinting services for the purposes of identity verification, background screening, licensing, credentialing, or employment suitability; and

WHEREAS, Service Provider is duly qualified to collect and transmit fingerprint impressions and associated biometric data in accordance with applicable law and industry standards; and

WHEREAS, the parties desire to set forth the terms under which the Service Provider will collect, use, retain, and transmit fingerprint data and for which the Client authorizes such collection and transmission.

Subject Information and Authorization

Last 4 digits of SSN (for identification):    Purpose of Fingerprinting:

Location of Collection:    Scheduled Collection Date:

Authorization and Consent

By signing below, the Subject and Client authorize Service Provider to collect fingerprint impressions and associated demographic information, and to transmit such biometric data to authorized government agencies, background screening entities, or other designated recipients necessary to fulfill the stated purpose. The authorization includes routine fingerprinting procedures and any standard quality-control reprints required by receiving authorities.

The Subject affirms under penalty of perjury that the information provided on this form is true, accurate and complete to the best of the Subject’s knowledge. The Subject further acknowledges that refusal to provide fingerprints may result in denial of the requested credential, license, or employment.

I authorize the collection, use, and disclosure of fingerprint and biometric data as described above.

Scope of Work

Describe services to be provided by Service Provider, including number of impressions, type of capture (live scan or ink), transmission responsibilities, and delivery of results:

Payment Terms

Total Fee:

Term and Termination

Term Start Date:    Term End Date:

Either party may terminate this authorization and any related services for cause upon written notice specifying the grounds for termination. Notice Period (days):

Confidentiality and Data Handling

Service Provider shall treat all fingerprint and biometric data as Confidential Information. Service Provider will implement administrative, physical, and technical safeguards to protect biometric data from unauthorized access or disclosure consistent with industry standards and applicable law. Service Provider shall retain data only as necessary to satisfy the intended purpose, regulatory requirements, or as otherwise required by law, and shall securely dispose of or return biometric data upon request or termination as required by the receiving authority.

Data Retention Period:

Release and Indemnification

Subject and Client release and hold harmless Service Provider and its agents from any claims arising from the performance of fingerprint collection and transmission, except to the extent caused by Service Provider’s gross negligence or willful misconduct. Client agrees to indemnify Service Provider for claims arising from incorrect or fraudulent information provided by Client or Subject.

Governing Law

This Authorization and any disputes arising out of or related to it will be governed by and construed in accordance with the laws of the state identified below.

Entire Agreement

This document constitutes the entire agreement between the parties regarding fingerprint collection, use, retention, and transmission, and supersedes all prior agreements and understandings, whether written or oral, relating to the same subject matter. Any modification must be in writing and signed by both parties.

Acknowledgment

The undersigned represent that they are authorized to execute this Authorization on behalf of the respective parties and that all information supplied herein is true and accurate.

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