Fingerprint Processing Application Form - Commonwealth Of Virginia (Page 2 of 2) in pdf

Fingerprint Processing Application Form - Commonwealth Of Virginia Page 2

Affirmation

I, the undersigned, certify that all information contained on the application is true and correct to the best of my knowledge

and I have not omitted any pertinent information. I understand that any misrepresentation, falsification or omission of the

pertinent information may be cause for denial and may result in criminal charges.

I hereby give consent and authorize the Virginia State Police and the Federal Bureau of Investigations to process my

fingerprints for a criminal history records check and report the results of such record to the Virginia Department of

Criminal Justice Services (DCJS). I authorize the Virginia State Police to archive my fingerprints for the purpose of

reporting any future criminal history information. I fully understand that if I am arrested this information will be reported to

the DCJS.

Print Name:

______________________________________________________

Signature:

______________________________________________________

Date:

_____________

mm/dd/yy

All fees are non-refundable. Applications received without payment will be returned.

Submit a check or money order payable to the TREASURER OF VIRGINIA,

or pay by credit card using the

Credit Card form

available at

—

this form must be included with your application package when paying by credit card.

10/2012

Page 2 of 2

Fingerprint Processing Application Form - Commonwealth Of Virginia Page 2