Applicant Clearance Card Team (Acct) Supply Order Form
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1APPLICANT CLEARANCE CARD TEAM (ACCT)
S U P P L Y O R D E R F O R M
Telephone #: (602) 223-2279
N O T E: Plea se dest roy an y O LD ORD ER FOR MS w ith a r ev is ion dat e p r io r t o 05- 20 10 .
Date: ______________________________
P l e a s e a l l o w 3 - 4 w e e k s f o r p r o c e s s i n g .
MAIL to the ATTENTION of: ___________________________ PHONE #:___________________________
AGENCY NAME: ________________________________________________________________________
AGENCY MAILING ADDRESS: _____________________________________________________________
CITY, STATE, ZIP CODE: _________________________________________________________________
C O M M E N T S : _______________________________________________________________________
___
FAX completed form to: ( 6 0 2 ) 2 2 3 - 2 9 4 7
OR
MAIL completed form to:
A r i z o n a D e p a r t m e n t o f P u b l i c S a f e t y
P . O . B o x 1 8 3 9 0
P h o e n i x , A Z 8 5 0 0 5 - 8 3 9 0
BOX 1
O r d e r I D E N T I T Y V E R I F I E D F I N G E R P R I N T ( I V P ) s u p p l i e s i n T H I S b o x f o r :
• Individuals applying for certification through the AZ State Board of Education under ARS 15-534
• Charter School Instructors under ARS 15-183
• Tutors and Teacher Prep Programs under ARS 13-534
Please limit your order to a 90 day supply since the application forms are subject to change.
C i r c l e a m o u n t r e q u e s t e d :
IDENTITY VERIFIED PRINTS APPLICATION
25
50
100
200
(
) -----
DPS # 802-07263
Note: If a supplement to the application is included with your order, you
.
will need to make a copy to go with each application distributed
FINGERPRINT CARDS -------------------------------------------------------- 25
50
100
200
POSTAGE PAID ENVELOPES ---------------------------------------------- 25
50
100
200
Note: Postage paid envelopes are only to be ordered for individuals submitting Identity Verified Fingerprint applications mailed within the United States.
BOX 2
Order REGULAR APPLICATION supplies in THIS box.
Please limit your order to a 90 day supply since the application forms are subject to change.
C i r c l e a m o u n t r e q u e s t e d :
REGULAR APPLICATION FORMS (
----------------- 25
50
100
200
DPS #802-06857)
Note: If a supplement to the application is included with your order, you
.
will need to make a copy to go with each application distributed
FINGERPRINT CARDS -------------------------------------------------------- 25
50
100
200
REGULAR RETURN ENVELOPES ----------------------------------------- 25
50
100
200
FOR ACCT USE ONLY:
ORDER REQUEST RECEIVED: ____________________________ORDER MAILED: ________________________
(Date / Badge)
(Date / Badge)
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