Livescan Consent Form

LIVESCAN CONSENT FORM

This Livescan Consent Form authorizes the capture and submission of biometric fingerprint impressions to authorized criminal justice and licensing agencies for the purpose indicated below. By signing this form the applicant grants permission for the collection, use and disclosure of fingerprint information as described herein and certifies the information provided on this form is true and correct.

Applicant Information

Date of Birth:

Place of Birth:

Sex/Gender:    Height:    Weight:

Eye Color:    Hair Color:

Identification Presented

Driver's License    State ID    Passport    Other    If Other, describe:

ID Number:    Issuing State/Country:

Requesting Agency / Employer

Purpose of Fingerprinting

Employment    Licensing/Certification    Volunteer    Immigration    Other

Fee and Payment

Livescan Fee Amount: $    Payment Method: Cash Card Check

Applicant acknowledges that payment for Livescan services is due at time of service and that any additional fees assessed by the requesting agency (such as processing or background check fees) are the responsibility of the applicant unless otherwise arranged in writing.

Consent, Authorization and Release

I, the undersigned applicant, hereby authorize the capture of my fingerprint impressions and the submission of those impressions to appropriate state and federal repositories for the purposes set forth above. I understand that the fingerprint images and associated personal information will be used to check criminal history records and may be retained and used by authorized agencies for positive identification, investigation, licensing, employment decisions, and record-keeping consistent with applicable statutes and regulations.

I consent to the disclosure of any criminal history record information returned in response to this submission to the requesting agency identified on this form. I release the Livescan operator, the agency submitting these fingerprints, and their employees and agents from liability for disclosure of such information to the requesting agency, provided disclosures are made in accordance with law. I understand that certain criminal history information may be exempt from public disclosure under applicable law.

Certification

I certify under penalty of perjury under the laws of the applicable jurisdiction that the foregoing is true and correct. I have read and understand this consent and release and have been given the opportunity to ask questions prior to signing. I understand that falsifying information on this form may subject me to penalties provided by law.

Operator / Technician Use Only

Technician Name:    Operator ID:

ORI / Reference Number:

Livescan Location / Facility:

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