Form 147 - Submisssion Of Fingerprints / Payment Of Fees To Nsp-Cid Page 2
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21. Name:_________________________________ Date of Birth: _______________ Last 4 SSN: _________
(Please print legibly)
Fingerprints on file with the commission? YES ☐
How was payment made to NSP? ☐NSP PAYPORT ☐CASH ☐CHECK SENT TO NSP Ck # ___________
2. Name:__________________________________________________________________________________
(Please print legibly)
Date of Birth: ______________________ Last 4 SSN: ____________________________
Fingerprints on file with the commission? YES ☐
How was payment made to NSP? ☐NSP PAYPORT ☐CASH ☐CHECK SENT TO NSP Ck # ___________
3. Name:__________________________________________________________________________________
(Please print legibly)
Date of Birth: ______________________ Last 4 SSN: ____________________________
Fingerprints on file with the commission? YES ☐
How was payment made to NSP? ☐NSP PAYPORT ☐CASH ☐CHECK SENT TO NSP Ck # ___________
4. Name:__________________________________________________________________________________
(Please print legibly)
Date of Birth: ______________________ Last 4 SSN: ____________________________
Fingerprints on file with the commission? YES ☐
How was payment made to NSP? ☐NSP PAYPORT ☐CASH ☐CHECK SENT TO NSP Ck # ___________
5. Name:__________________________________________________________________________________
(Please print legibly)
Date of Birth: ______________________ Last 4 SSN: ____________________________
Fingerprints on file with the commission? YES ☐
How was payment made to NSP? ☐NSP PAYPORT ☐CASH ☐CHECK SENT TO NSP Ck # ___________
6. Name:__________________________________________________________________________________
(Please print legibly)
Date of Birth: ______________________ Last 4 SSN: ____________________________
Fingerprints on file with the commission? YES ☐
How was payment made to NSP? ☐NSP PAYPORT ☐CASH ☐CHECK SENT TO NSP Ck # ___________
I hereby certify that fees of $28.75 per person have been submitted directly to the Nebraska State Patrol – CID
office. The undersigned certifies on behalf of the Corporation, LLC, Partnership or Licensee that it is understood
that a misrepresentation of fact is cause for rejection of this application or suspension, cancellation or revocation of
any license issued.
Name (Print):
Title:
Signature:
Date:
FORM 147
REV JAN 2016
PAGE 2
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