Criminal Background Check Identity Verification Form

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Criminal Background Check Identity Verification Form Instructions
Criminal Background Check Identity Verification Form:
 Fill out all the required boxes on the fingerprint card using the information below prior to taking the fingerprints.
 Fill out all the required information on the Criminal Background Check Identity Verification Form prior to taking the
 Once fingerprinted, have the person that took your prints fill out the “Fingerprint Technician Information” portion of the
Criminal Background Check Identity Verification Form and seal the fingerprint card and the Criminal Background
Check Identity Verification Form in a signed envelope. You’ll submit this sealed and signed envelope with your
completed application to the Board of Pharmacy.
FBI Fingerprint Card:
 You MUST use a standard FBI fingerprint card, form No. FD-258 used by the FBI for noncriminal fingerprinting.
You can obtain this card at your local police department, sheriff’s office, state police office, or you can contact the State
Board of Pharmacy office to have one sent to you.
Have fingerprints done by someone APPROPRIATELY TRAINED to collect them. A delay in the processing of your
FBI criminal background check is commonly caused by incomplete FBI fingerprint cards and poor quality of
Your local police or sheriff’s department may be willing to accommodate you. There may or may not be a fee
involved. The Arkansas State Police ID Bureau in Little Rock, on Geyer Springs Road at I-30, will do your
fingerprints WITHOUT charge Monday through Friday from 8:30 a.m. to 4:30 p.m.
 DO NOT CONTACT the Arkansas State Police or the FBI about the status of your criminal background check.
Those agencies will notify the Arkansas State Board of Pharmacy.
Fields to be completed on the Fingerprint Card
(Type or print, black ink only - Fingerprints must be done in BLACK Ink.)
Last name, First name, Middle name
Signature of person fingerprinted – be sure to sign this field in front of the fingerprint technician
Aliases (other names you have used, including nicknames, maiden names, other married names, etc.)
Date of birth (MM/DD/YYYY)
Residence of person fingerprinted (street address or post office box, city, state, zip)
Citizenship (i.e., United States, England, Mexico)
Sex: M= Male, F= Female
Race: A=Asian; W=White; B=Black; I=American Indian, H=Hispanic, U=Unknown
Height (in pounds)
Weight (foot’ inches”)
Eyes: BLU=Blue; BRO=Brown; BLK=Black; GRY=Gray; GRN=Green; HAZ=Hazel; XXX=Unknown
Hair: BAL=Bald; BRO=Brown; BLK=Black; SDY=Sandy; GRY=Gray; WHI=White; BLN=Blond; RED=Red;
Place of birth (city/state or foreign country)
Employer and address (“none” if you are unemployed)
Reason Fingerprinted - This block MUST read: Arkansas State Board of Pharmacy – ACA § 17-92-317
Social Security Number
Leave all other spaces blank (i.e., OCA, FBI, MNU)
If an individual is missing one or more fingers, a notation in the fingerprint block(s) indicating why a partial or missing
image exists must be written in. Handwritten notation recommended for fingerprint submissions include:
AMP=amputated; TI=tip amputated; Missing at Birth; Cut off; Shot off; Deformed; and Missing.


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