(1) Originating Agency Number (ORI#)
HSK (3) Statute Number. 30:6D-64 (4) Reason for Fingerprinting. HUMAN SERVICES PRIVATE CONTRACTOR (5) Document Type. RB2 (6) Payment Information. BILL STATE AGENCY (7) Contributor’s Case # (Unique Identifier) PC (ENTER COST CODE) (8) Miscellaneous (9) First Name (10) MI (11) Last Name (12)Daytime Phone Number - (13) Social Security Number ................
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