Form Itcd-96 - Registration For Authorization For Record Checks
Download a blank fillable Form Itcd-96 - Registration For Authorization For Record Checks in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Itcd-96 - Registration For Authorization For Record Checks with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
CRIMINAL JUSTICE INFORMATION SYSTEMS-CENTRAL REPOSITORY
REGISTRATION FOR AUTHORIZATION FOR RECORD CHECKS
This is a NEW registration.
This is a CHANGE to a current registration.
List Authorization Number if known: _____________________
I. COMPANY OR AGENCY NAME: _______________________________________________
CONTACT PERSON: ______________________________________________________
(Person who will be handling the criminal history record information from CJIS)
CONTACT PERSON’S TITLE: ______________________________________
CONTACT PERSON’S TELEPHONE NUMBER: ___________________________________
MAILING ADDRESS: _____________________________________________________
CITY, STATE AND ZIP CODE: _______________________________________________
E-mail address_____________________________________
Fax Number: _____________________________________
Business License#:________________________________
Please include a copy of your business license, IRS paperwork EIN# and a short bio about your
agency.
II. REASON FOR REQUEST:
___ ADULT DEPENDENT CARE (For Maryland Adult Dependent Program Only)
___ ATTORNEY/CLIENT
___ CHILD CARE (Licensed Agencies working with Children in Maryland Only)
___ CRIMINAL JUSTICE (For Criminal Justice Agencies ONLY)
___ GOVERNMENT EMPLOYMENT – Federal ___ State ___ Local ___
____ GOVERNMENT LICENSING/CERTIFICATION
IF AUTHORIZED BY STATUE, ENTER STATUTORY CITATION: _____________________
III. CERTIFY THAT UNDER THE SPIRIT AND INTENT OF THE LAWS OF MARYLAND, I UNDERSTAND THAT DATA
RETURNED TO ME CAN ONLY BE USED AS REQUESTED AND THAT I AM NOT AUTHORIZED FOR FURTHER
DISSEMINATION.
____________________________
SIGNATURE
____________________________
Date: ______________
TITLE
******************************************************************************************
MAIL, Email or FAX COMPLETED FORM TO:
CJIS AUTHORIZATION ADMINISTRATOR
POST OFFICE BOX 32708
PIKESVILLE, MARYLAND 21282-2708
Dlcjiscustomerservice7_dpscs@maryland.gov
Fax# 410-653-6320 or 5690
Form/ITCD-96
Made Fillable by Backgroundcheck.net
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal