Form Il486-2226 - Fingerprint Consent Form Medical - Cannabis Dispensing Organization Applicant - Illinois Department Of Financial And Professional Regulation

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State of Illinois
Fingerprint Consent Form
Illinois Department of Financial
Medical Cannabis Dispensing Organization Applicant
and Professional Regulation
Pursuant to the Compassionate Use of Medical Cannabis Pilot Program Act (Act) and Regulations, 410 ILCS 130 and 68 IAC 1290,
applicants for a Medical Cannabis Dispensing Organization and Dispensary Agents must have a UCIA, 20 ILCS 2635, fi ngerprint-based
criminal history record information background check. The Illinois Department of Financial and Professional Regulation will comply with
the rules and regulations concerning your criminal background check in connection with the Act, UCIA and applicable federal statutes.
This form captures the information required by licensed livescan fi ngerprint vendors to ensure your fi ngerprints are submitted properly.
A transaction control number (TCN) will be issued by the livescan fi ngerprint vendor at the time of transmission of fi ngerprints. The TCN
is verifi cation your prints were taken and the vendor must fi ll in the TCN on this consent form. The livescan vendor will use the applicant
information to help confi rm your identifi cation documentation before the fi ngerprints are taken. This document also serves as your con-
sent form. The form must be signed by you 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 Financial and Professional Regulation for
review.
PURPOSE CODE:
Facility Information
PURPOSE CODE:
REQUESTING AGENCY ORI IDENTFIER:
IL920711Z
CDA Cannabis Dispensing Agent
REQUESTING AGENCY NAME AND ADDRESS:
Illinois Department of Financial and Professional Regulation
Medical Cannabis Division, 100 West Randolph Street, 9th fl oor, Chicago, Illinois 60601
CONTACT E-MAIL AND PHONE #:
CONTACT PERSON NAME:
Deputy Director of Medical Cannabis
FPR.MedicalCannabis@Illinois.gov
(312)814-1690
FACILITY COST CENTER: (IF ANY)
TRANSACTION CONTROL NUMBER (TCN):
Cost Center of the Livescan Fingerprint Vendor
Applicant Information
NAME:
GENDER:
RACE:
DATE OF BIRTH (mm/dd/yyyy):
SSN:
DRIVERS LICENSE #:
DRIVERS LICENSE STATE: REGISTRY ID #:
Live Scan Vendor/Appointment Information
LIVE SCAN FINGERPRINT VENDOR NAME:
ADDRESS:
PHONE NUMBER:
APPOINTMENT DATE & 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 fi le. I am aware and understand that my fi ngerprints may be retained and will
be used to check the criminal history record information fi les of the Illinois State Police and/or the Federal Bureau of Investigation where
permitted by law. I also understand that if my photo was taken, my photo may be shared only for employment or licensing purposes. I
further understand that 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 Section 16.34 and Chapter 20 ILCS 2630/7 of the
Criminal Identifi cation Act.
Applicant Consent
APPLICANT NAME: (printed)
DATE:
APPLICANT NAME: (signature)
DATE:
IL486-2226 4/15

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