Form Dpssp 6696 - Authorization To Disclose Criminal History Records Information - 2016

SUBMIT TO:

Louisiana State Police

Bureau of Criminal Identification and Information

P.O. Box 66614 (Mail Slip A-6)

Baton Rouge, LA 70896

THE FEE FOR PROCESSING A STATE BACKGROUND CHECK IS $26. FOR FBI PROCESSING, WHERE AUTHORIZED OR REQUIRED, THERE IS

AN ADDITIONAL $12 FEE.

Acceptable forms of payment include: Cashier Check, Business Check with pre-printed business name or Money Order

Credit Card payments are accepted when paying in person at Louisiana State Police Headquarters

**FORMS MUST BE FILLED OUT IN INK AND BE REVIEWED BY SUBMITTING AGENCY/INDIVIDUAL FOR ACCURACY**

****FINGERPRINTS ARE NECESSARY FOR A POSITIVE IDENTIFICATION****

_____________________________________________________________________________________________________________________________________________________________________________________

****PLEASE PRINT****

________________________________________ _____________________________________

AGENCY, FACILITY OR INDIVIDUAL

AGENCY, FACILITY AUTHORIZED REPRESENTATIVE OR INDIVIDUAL

________________________________________ _____________________________________

MAILING ADDRESS

SIGNATURE OF AUTHORIZED REPRESENTATIVE/INDIVIDUAL

_________________________________________ (_______)___________________________

AGENCY, FACILITY OR INDIVIDUAL PHONE NUMBER

CITY

STATE

ZIP CODE

AGENCY OR FACILITY E-MAIL ADDRESS

Request For: (pick one only)

□ ALCOHOL BEVERAGE OUTLET

□ LA BOARD CHIROPRACTIC EXAMINERS

□ BEHAVIOR ANALYST BOARD

□ LA PHYSICAL THERAPY BOARD

□ BOARD OF EXAMINERS (

□ LA STATE BOARD SOCIAL WORK EXAMINERS

)

PSYCHOLOGIST

□ BOARD OF EXAMINERS (

□ LICENSED PROFESSIONAL COUNSELORS

)

SPEECH/LANGUAGE PATH. & AUDIO.

□ BOARD OF NURSING HOME ADMINISTRATORS

□ MEDICAL EXAMINERS

□ CASA

□ OFFICE OF FINANCIAL INSTITUTIONS

□ COURT ORDER ADOPTION

□ OMVC – COMMERCIAL DRIVING EXAM ADMINISTER

□ CRIMINAL JUSTICE EMPLOYEE

□ OMVE – EMPLOYEE ISSUING COMMERCIAL DL

□ DAYCARE / WORKING WITH CHILDREN

□ OMVI – CONTRACT PROCESS INQUIRY/TRANSACTION

□ DENTISTRY BOARD

□ OMVT – AUTO TITLE COMPANY / PUBLIC TAG AGENT

□ DEPT. OF AGRICULTURE AND FORESTRY

□ PHARMACY BOARD

□ DEPT. HEALTH AND HOSPITALS

□ POST SECONDARY EDUCATION

□ DEPT. OF INSURANCE – FRAUD DIVISION

□ PRACTICAL NURSING

□ DEPT. OF REVENUE

□ PRIVATE ADOPTION

(Public Registry of Motion Picture Investor Tax Credit)

□ DCFS ABUSE/NEGLECT INVESTIGATION

□ PRIVATE INVESTIGATORS

□ DCFS CARETAKER

□ PRIVATE SECURITY

□ DCFS FOSTER/ADOPTIVE

□ PUBLIC HOUSING

□ DCFS PERSONNEL

□ REGISTERED NURSING

□ DRUG AND DEVICE DISTRIBUTORS

□ RELIGIOUS ACTIVISTS

□ EMPLOYERS

□ SCHOOL

□ FIREFIGHTERS

□ SUPREME COURT COMMITTEE BAR ADMISSION

□ FIRE MARSHAL

□ TAXI DRIVERS

□ GESTATIONAL CONTRACTS

□ TESS WINDOW TINT

□ HEALTH CARE PROVIDER (Non Licensed)

□ VOLUNTEER LOUISIANA COMMISSION

□ JUVENILE DETENTION CENTER

□ WORKING WITH CHILDREN

APPLICANTS FULL NAME: _______________________________________________________________________________

****PRINT – USE INK****

LAST

FIRST

MIDDLE

{INCLUDE MAIDEN NAME & PREVIOUS MARRIED NAMES IF APPLICABLE}

APPLICANTS SIGNATURE: ______________________________________________________

APPLICANTS SOCIAL SECURITY # _ _ _ - _ _ - _ _ _ _

DATE OF BIRTH: _ _ / _ _ / _ _

ID or DRIVERS LICENSE #___________________& STATE

______ RACE ____

SEX ____

POSITION OR LICENSE APPLIED FOR ________________________________

AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION

By my signature above, I hereby authorize the Louisiana State Police to release all pertinent criminal record information maintained in their files, other

states files, or the FBI files (if applicable) which may confirm or deny my eligibility with the facility or agency named above. Pursuant to Title 28, C.F.R.,

Section 16.34, officials making the determination of suitability for licensing or employment shall provide the opportunity to complete, or challenge the

accuracy of, the information contained in the FBI identification record.

DPSSP 6696

Revised 10/01/2016