MICHIGAN STATE POLICE
LIVESCAN FINGERPRINT BACKGROUND CHECK REQUEST
AUTHORITY: MCL 28.162, MCL 28.214, MCL 28.248, & MCL 28.273; COMPLIANCE: Voluntary. However failure to complete this form will result in denial of request.
Purpose: To conduct a fingerprint based background check for employment, to volunteer, or for licensing purposes as authorized
I. Authorizing Information: Please ensure the correct fingerprinting reason code and agency ID are used. The Michigan State Police (MSP) will charge for
second requests due to incorrect codes.
1. Fingerprint Code
2. Requestor/Agency ID
3. Agency Name
SE-MICHIGAN SCHOOL EMPLOYMENT 91587M
MOREY PUBLIC SCHOOL ACADEMY
II. Applicant Information: Type or clearly print answers in all fields before going to be fingerprinted.
1a. Last Name
1b. First Name
1c. Middle Initial
2. Any Alternative Names, Last Names, or Aliases
3. Social Security Number (Optional)
4. Place of Birth
5. Date of Birth
6. Phone Number
7. Driver's License / State Identification Number 8. Issuing State
(State or Country)
9. Home Address
12. ZIP Code
17. Eye Color
18. Hair Color
III. Livescan: Must be completed by the Livescan operator at the time of fingerprinting.
*After fingerprinting, the applicant shall return this signed and completed document to the requesting agency. The Livescan operator must return a
completed copy of the form to the applicant.
1. Date Printed
Picture ID Type Presented
3. Transaction Control Number (TCN)
4. Livescan Operator
I understand that my personal information, and biometric data being submitted by Livescan, will be used to search against
identification records from both the Michigan State Police (MSP) and Federal Bureau of Investigation (FBI) for the purpose listed
above. I hereby authorize the release of my personal information for such purposes and release of any records found to the
authorized requesting agency listed above.
During the processing of this application, and for as long as my fingerprints and associated information/biometrics are retained at
the State and/or FBI, they may be disclosed without my consent as permitted by MCL 28.248 and the Federal Privacy Act of
1974, 5 USC § 552a, for all applicable routine uses published by the FBI, including the Federal Register and for the routine uses
for the FBI's Next Generation Identification.
Routine use includes, but is not limited to, disclosure to: governmental or authorized nongovernmental agencies responsible for
employment, contracting, licensing, security clearances, and other suitable determinations; local, state, tribal, or federal law
enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.
Procedure to obtain a change, correction, or update of identification records:
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and
wishes changes, corrections, or updating of the alleged deficiency, he/she should make application directly to the agency which
contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or
completeness of any entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod.
D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted
the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly
from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in
accordance with the information supplied by that agency. (28 CFR § 16.34)