Fingerprinting Request Application Form

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FINGERPRINTING REQUEST APPLICATION
Last Name: __________________ First Name: __________________
Aliases or Nicknames: _________________ Social Security #__________________
*Have you been a resident of Ohio for the past five consecutive years?
YES
NO
MOST CURRENT ADDRESS: ______________________________________________________
**List your legal residence
(include complete street address, apartment number, city, state, and zip code)*
Phone number to reach you at: ___________________________
Please be sure to complete this section for all areas of need
Reason you are being fingerprinted:
Child Care Center
Public School District
OPOTA
Security
Home Health/Elderly
Home Health/Children
Massage Therapy
Dental
Medical Imaging
Nursing
Occupational/Physical Therapy
Other: _________________
*If you are not an Owens member, please skip to Licensing purposes
Name of person/department at Owens to receive results:____________________________________
Applicant or Prospective Owens employees: Department index to be charged:_________________________________
Supervisor/Department Representative Signature:_________________________________________ Campus___________
If this request is for licensing purposes and a direct copy needs to be sent, please select from the
list below:
Ohio Board of Nursing
Ohio Department of Education
OPOTA
Ohio Dept. of Liquor Control
Ohio Dept. of Public Safety/PISG
Ohio Department of Insurance
Other License: ___________________________
Mail results to this address -Please fill out completely
**will be sent by BCI OR FBI NOT Owens
**PLEASE NOTE WE CANNOT FAX RESULTS TO EMPLOYERS/BUSINESSES**
Business Name ____________________________________________
Business Address__________________________________________
City_________________________
State_________________
Zip___________
:
IF RESULTS ARE NOT BEING MAILED, CHECK AND INITIAL HERE
____________
I would like to pick up a copy when ready Yes
No
**(You cannot receive a copy if there is an address above)
Check the appropriate box: (At least one background option must be selected.)
BCI only
FBI only
BCI and FBI together
.
DATE STAMP
______________________________________________________
_________________
Signature of person being printed
Date
______________________________________________________
_________________
Date
Signature of Dept. of Public Safety Customer Service Representative
2/2015

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