Application For Qualifying Patient Registry Identification Card Page 3
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4State of Illinois
Illinois Department of Public Health
Fingerprint Consent Form
Medical Cannabis Registry Identification Card
Pursuant to the Compassionate Use of Medical Cannabis Pilot Program Act, applicants for a Medical Cannabis Registry
Identification Card must have a UCIA fingerprint-based criminal history record information background check. The Illinois
Department of Public Health will comply with rules and regulations concerning your criminal background check authorized by
the Compassionate Use of Medical Cannabis Pilot Program Act (410 ILCS 130) and the UCIA (20 ILCS 2635). This form
captures the information required by licensed live scan fingerprint vendors to ensure your fingerprints are submitted properly.
A transaction control number (TCN) will be issued by the live scan fingerprint vendor at the time of transmission of fingerprints.
The TCN is verification your prints were taken and the vendor must fill in the TCN on this consent form. The live scan vendor
will use the applicant information to help confirm your identification documentation before the fingerprints are taken. This
document also serves as your consent form. The form must be signed in order to authorize the release of any criminal history
record information that may exist. The results of the criminal history background check will be forwarded to the Illinois
Department of Public Health for review.
Facility Information
Requesting Agency ORI Identifier:
Purpose Codes:
❑
LG1407112
MMP Medical Marijuana Patient
❑
MMP Medical Marijuana Caregiver
Requesting Agency Name and Address:
Illinois Department of Public Health, 535 West Jefferson Street, Springfield, Illinois, 62761-0001
Contact Person Name:
Contact E-mail and Phone #:
Division of Medical Cannabis
DPH.MedicalCannabis@illinois.gov and 217-782-3300
Facility Cost Center (If any):
Transaction Control Number (TCN):
Note: Cost is responsibility of the applicant
Applicant Information
Name:
Sex:
Race:
Date of Birth (mm/dd/yyyy):
Select
SSN (optional):
Drivers License #:
Driver’s License State:
Livescan Vendor/Appointment Information
Live Scan Fingerprint Vendor Name:
Address:
Phone Number:
Appointment Date:
Appointment Time:
Privacy Statement
I, the undersigned, hereby authorize the release of any criminal history record information that may exist regarding me from any agency,
organization, institution or entity having such information on file. I am aware and understand my fingerprints may be retained and will be used to
check the criminal history record information files of the Illinois State Police and/or the Federal Bureau of Investigation where permitted by law. I
also understand if my photo was taken, my photo may be shared only for employment or licensing purposes. I further understand I have the right
to challenge any information disseminated from these criminal justice agencies regarding me that may be inaccurate or incomplete pursuant to
Title 28 Code of Federal Regulation 16.34 and Chapter 20 ILCS 2630/7 of the Criminal Identification Act.
Applicant Consent
Applicant Name (printed):
Date:
Applicant Name (signature):
Date:
Page 3 of 4
Printed by Authority of the State of Illinois
IOCI 16-532
P.O.#3116010
10M
3/16
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Parent category: Medical