Fast Fingerprint Card Scan Authorization Form printable pdf download

OUT OF STATE LICENSING APPLICANT

TEXAS DEPARTMENT OF INSURANCE

This document is your FAST Fingerprint Pass for a state and national criminal history record check. Please register

or by calling 1-888-467-2080. When registering

your fingerprint submission by visiting

your fingerprint submission you will be prompted by IdentoGO for the following additional personal data: Date

of Birth, Sex, Race, Ethnicity, Skin Tone, Height, Weight, Eye Color, Hair Color, Place of Birth, Driver License

Number and Home Address. Requested data is required by the Texas Department of Public Safety to process

your background check. These data elements have been omitted from this document in order to better protect the

security of your personal information. You may pay for FAST services online with a credit card or by mail with a check

or money order only made payable to MorphoTrust USA. Your fingerprints will be submitted to the Texas Department of Public Safety and the Federal

Bureau of Investigation.

Logon to

Select: Yes, I have a FAST Fingerprint Pass

Select: Texas

Enter: TX920540Z

Select: Online Scheduling

10. Select: Pay for Ink Card Submission

Select: English or Espanol

11. Follow the prompts to enter requested information.

Enter: First and Last Name

12. Write in:

RegID

Select: All Others

13.

Mail in this completed form with your completed Fingerprint

Select: Option A – Electronic Submission

Card to address below.

Section One: Qualified Entity Information

ORI#:

TX920540Z

RFP: Government Code 411.106

Original TCN:

(If resubmission for rejected fingerprints)

Agency/Entity/Organization Name: _Texas Department of Insurance

Section Two: Applicant Name (To be completed by applicant)

Last: ______________________________________

First: _________________________________

Middle: ________________________

(Please print)

Section Three: Waiver Information (To be completed and signed by applicant)

I certify that all information I provided in relation to this criminal history record check is true and accurate. I authorize the Texas Department of Public

Safety (DPS) to access Texas and Federal criminal history record information that pertains to me and disseminate that information to the designated

Authorized Agency or Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer, through the DPS Fingerprint-based

Applicant Clearinghouse of Texas and as authorized by Texas Government Code Chapter 411 and any other applicable state or federal statute or policy.

I authorize the Texas Department of Public Safety to submit my fingerprints and other application information to the FBI for the purpose of comparing the

submitted information to available records in order to identify other information that may be pertinent to the application. I authorize the FBI to disclose

potentially pertinent information to the DPS during the processing of this application and for as long hereafter as may be relevant to the activity for which

this application is being submitted. I understand that the FBI may also retain my fingerprints and other applicant information in the FBI’s permanent

collection of fingerprints and related information, where all such data will be subject to comparisons against other submissions received by the FBI and

to further disseminations by the FBI as may be authorized under the Federal Privacy Act (5USC 552a(b)). I understand I am entitled to obtain a copy of

any criminal history record check and challenge the accuracy and completeness of the information before a final determination is made by the Qualified

Entity. I also understand the Qualified Entity may deny me access to children, the elderly, or individuals with disabilities until the criminal history record

check is completed. If a need arises to challenge the FBI record response, you may contact the agency that submitted the information to the FBI, or you

may send a written challenge request to the FBI's Criminal Justice Information Services (CJIS) Division at FBI CJIS Division, Attention: Correspondence

Group, 1000 Custer Hollow Road, Clarksburg, WV 26306.

Signature: ______________________________________________________

Date: __________________________________________

Section Four: Fingerprint Cards and Payment

Your fingerprint cards must include the following personal data: Date of Birth, Sex, Race, Height, Weight, Eye Color, Hair

Color, Place of Birth, Home Address, and Social Security Number. Requested data is required by the Texas Department of

Public Safety to process your background check. Mail your card and payment (if not paid online) to:

MorphoTrust USA

RegID:

__________________________________________

Attn: Texas Card Scan

(provided at the end of online registration)