Application For A Designated Caregiver Registry Identification Card (Page 3 of 4) in pdf

State 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 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), the UCIA (20 ILCS 2635) and applicable federal

statute. 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:

❑

MMP Medical Marijuana Patient

IL920709Z

❑

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):

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 that 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 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 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 17-8

P.O.#3117020

9/16

Application For A Designated Caregiver Registry Identification Card Page 3

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