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31178505715000STATE OF MARYLANDDEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICESCRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORYLIVESCAN PRE-REGISTRATION APPLICATIONAPPLICANT INFORMATION (PLEASE TYPE OR PRINT CLEARLY)Last Name:First Name:Middle Name:Alias Name (AKA):Date of Birth:SSN:111887043815005772154381500Gender:MaleFemale(Choose One Only)Height:ft.inchesWeight:lbs.Eye Color:Hair Color:546227051435003462020514350010947405143500192722551435003854454508500Race: Black (B) White (W) Asian/Pacific Islander (A) American Indian/Alaskan Native (I) Unknown (U) (Choose One Only)Place of Birth: (State or Country)Citizenship: (Country)Current Address:City:State:ZIP Code:-Daytime Phone: (xxx-xxx-xxxx)Evening Phone: (xxx-xxx-xxxx)Driver’s License #: (2-LETTER STATE CODE FOLLOWING ALL NUMBERS AND LETTERS NO DASHES)Miscellaneous ID #: (2-LETTER TYPE OF IDENTIFICATION HYPEN (-) FOLLOWING ALL NUMBERS AND LETTERS NO DASHES) AGENCY INFORMATIONAgency Authorization #: (10-digit number provided by Requesting Agency)Child Care Authorization #: (Request Code-Type Child Care/ example: 11XXXXXXXX/ see handout)ORI # (required): (Originating Agency Identifier)CRI # (required): (Controlling Agency Identifier)OCA # (if required): (Originating Agency Case Number)Reason Fingerprinted: (Drop-Down List or Selectable Table Containing Employment or License Description)Position Applied For: Request Code-Type: (Choose One Only)/Type of Transaction: NFUF, MAP, STATE Only, FBI Only 23749047942500 0-VISA CHECK / GOLD SEAL STATE23749061849000 2-INDIVIDUAL CHALLENGE STATE237490768985003-RACING COMMISION STATE237490909320005-ADULT DEPENDENT CASE STATE2374901050290007-GOVERNMENT LICENSING (FULL BACKGROUND) NFUF2374901198245008-GOVERNMENT LICENSING (STATE CHECK ONLY) STATE2374901449070009-PUBLIC SERVICE COMMISION (STATE CHECK ONLY) STATE237490171386500ATTORNEY CLIENTS/RECORD CHECKS STATE237490184086500CHILD CARE FULL BACKGROUND NFUF237490196786500CHILD CARE VOLUNTEER NFUF237490209486500D-EMPLOYMET – STATE OTHER THAN CRIMINAL JUSTICE (FULL BACKGROUND)Only the Counties Listed: Anne Arundel County, Carroll County, Howard County, Washington County, and Prince George’s County NFUF237490269811500237490257111500E-PRIVATE EMPLOYERS STATE237490283146500F-MARYLAND MENTORS NFUFG-DEPT. OF JUVENILE SERVICES (STATE CHECK ONLY) STATE3835407245350038354048958500H-EMPLOYMENT – STATE OTHER THAN CRIMINAL JUSTICE (STATE CHECK ONLY) STATEI-EMPLOYMENT (FEDERAL) STATE38354085788500J-CRIMINAL JUSTICE APPLICATION (STATE CHECK ONLY) STATE383540109918500K-EMPLOYMENT (LOCAL GOVERNMENT) STATE383540122618500L-CHILD CARE DISCLOSURE ONLY STATE383540135318500M-PUBLIC SERVICE COMMISSION (FULL BACKGROUND) NFUF383540182308500383540159448500N-CRIMINAL JUSTICE APPLICATION (FULL BACKGROUND) MAP XXXXX383540195072000O-PRECIOUS METALS DEALER NFUF383540207772000R-INDIVIDUAL REVIEW (CR001) STATE383540220218000S-RACING COMMISSION (FULL BACKGROUND) NFUF383540232473500U-HAZMAT NFUFV-VISA CHECK / IMMIGRATION STATE383540245364000383540269684500W-DEPT. OF JUVENILE SERVICES (FULL BACKGROUND) NFUFZ-ADOPTION (STATE CHECK ONLY) STATE383540283083000X-FBI ONLY FBIDisclosure:26568405016500Conviction / Probation Before Judgment: Yes NoPending Any Criminal Charges: Yes NoSignature: ??????????????????????????????????????????????????????????????????????? Date: ????????????????????????????????????????????????????????????????????? ................
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