Form Ri-030 - Livescan Fingerprint Background Check Request - Michigan State Police Page 2
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2RI-030 (09/2014)
Print Form
MICHIGAN STATE POLICE
LIVESCAN FINGERPRINT BACKGROUND REQUEST
AUTHORITY: MCL 28.214, MCL 28.273 & MCL 28.162; COMPLIANCE: Voluntary, however failure to complete this form will result in denial of request.
Purpose: To conduct a fingerprint-based background check for employment, to volunteer, or for licensing purposes as authorized
by law.
I. Fingerprint Reason
1. Code
2. Requestor/Agency ID
3. Agency Name
LL
1479J
MI DEPT OF LICENSING AND REGULATORY AFFAIRS - LIQUOR CONTROL
II. Applicant Information: Type or clearly print answers in all fields before going to be fingerprinted.
1a. Last Name
1b. First Name
1c. Middle Initial
1d. Suffix
2. Any Alternative Names, Last Names, or Aliases
3. Social Security Number (Optional)
4. Place of Birth
5. Date of Birth
6. Phone Number
7. Driver License State 8. Driver License Number
(State or Country)
9. Address
10. City
11. State
12. ZIP Code
13. Sex
14. Race
15. Height
16. Weight
17. Eye Color
18. Hair Color
III. Live Scan: Must by completed by the Livescan Operator at the time of fingerprinting.
1. Date Printed
Picture ID Type Presented
3. TCN
4. Live Scan Operator
NOTE: After fingerprinting, applicant must return signed and completed document to the requesting agency. Livescan Operator
must return completed copy to applicant.
I understand that my personal information and biometric data being submitted by livescan will be used to search against criminal
identification records from both the Michigan State Police (MSP) and Federal Bureau of Investigation (FBI) for the fingerprint
reason listed above. I hereby authorize the release of my personal information for such purposes and release any records found
to the authorized requesting agency listed above.
During the processing of this application, and for as long as your fingerprints and associated information/biometrics are retained
at the State and or FBI, they may be disclosed without your consent as permited by the Federal Privacy Act of 1974 (Pub. L.
93-579) for all applicable routine uses published by the FBI, including the Federal Register and the FBI's Next Generation
Identification (NGI).
Routine uses include, but is not limited to, disclosure to: governmental or authorized non-governmental agencies responsible for
employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal or federal law
enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.
Signature:
Date:
Procedure to obtain a change, correction or update of identification records:
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and
wishes changes, corrections or updating of the alleged deficiency, he/she should make application directly to the agency which
contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or
completeness of any entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod.
D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted
the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly
from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in
accordance with the information supplied by that agency. (28 CFR §16.34)
** ENSURE THAT THE CORRECT FINGERPRINTING REASON CODE AND AGENCY ID ARE USED. MSP WILL CHARGE
FOR SECOND REQUESTS DUE TO INCORRECT CODES. **
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