Maryland
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STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
|Livescan pre-registration application |
| Applicant Information (Please TYPE OR PRINT CLEARLY) |
|Name: |
|Date of birth: |SSN: |Gender: Male Female (Please check) |
|Height: ft. inches | Weight: lbs. |Eye Color: |Hair Color: |
|Race: Black White Asian/Pacific Islander Native American Other (Please check) |
|Place of Birth: |Citizenship: |
|Current address: |
|City: |State: |ZIP Code: - |
|Daytime Phone: |Evening Phone: |Driver’s License #: |
|agency information |
|Agency Authorization #: 1600003694 |
|ORI # (if required): MD920530Z |Reason fingerprinted? |
|Position Applied for: |
|Request Type: (Choose one ONLY) | |
|Adult Dependent Care |Government Licensing or Certification |
|Attorney/Client |Immigration/VISA |
|Child care |Individual Challenge |
|Criminal Justice |Individual Review |
|Gold Seal/ Adoption |MSP Licensing |
|Gold Seal/Letter/VISA |Private Party Petition |
|Government Employment |Public Housing |
|Mail Response to: |
|(Mailing option only available for Visa Gold Seal and/or Individual Review) |
| |
| |
|Name: Maryland Board of Occupational Therapy Practice, Attn: Lauren Murray |
|________________________________________________________________________________________ |
| |
|Address: Spring Grove Hospital Campus, 55 Wade Avenue, Bland Bryant Bldg., 4th Floor |
|_______________________________________________________________________________________ |
| |
|City, State, Zip code: Baltimore, MD 21228 |
|______________________________________________________________________________ |
CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY
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