Livescan Form For Fingerprinting - Summit Academy

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Livescan
Fingerprint Information Form
Please remove this form from this packet and give to the fingerprinting provider or agency.
It is the policy of the Michigan Department of Education and of MEP Services that anyone working at a Michigan public school
must be fingerprinted and finger print results must be on file with MEP Services prior to their first day of work. This includes
all employees, independent contractors, and vendors working on a regular or continuous basis or under contract. Please
follow the directions below in order to schedule your appointment for fingerprinting. MEP Services will receive your print results
within 2-3 days of your appointment, and at that time we will inform the school office manager that you are eligible to begin
your assignment. Please contact MEP Services if you have any questions.
Appointments can be made online at (or call L-1 Enrollment at 866-226-2952) or any Livescan Facilitator
You will need to bring this form, a picture ID and a check for payment to your fingerprint appointment. Rates very by location.
The following section needs to be completed for the Livescan fingerprinting Facilitator.
APPLICANT INFORMATION
Applicant Name: ________________________________________________________________________
Maiden or Alias Name: ___________________________________________________________________
Gender: ___________ Eyes: _____________ Hair: ____________ Height: ___________ Weight: _________
Race: Asian: _________ Black: __________ American Indian: _________ White: ___________ Other: ___________
Date of Birth:_______________
Place of Birth (State): _____________ Citizenship: __________________
Applicant Address: _____________________________________________________________________
City: ____________________________ State: ________________ Zip: _______________
Applicant Phone Number: _____________________________________________
REQUESTING AGENCY INFORMATION
Please use the appropriate codes below for the listed agency:
_________ Ann Arbor Learning Community
Agency ID: 6772E
_________ American Montessori Academy
Agency ID: 13906H
_________ Charyl Stockwell Academy/CSPA
Agency ID: 14331K
_________ Crescent Academy
Agency ID: 13907M
_________ Conner Creek Academy East/Michigan Collegiate H.S.
Agency ID: 14408L
_________ Huron Academy
Agency ID: 14334P
_________ Kensington Woods High School
Agency ID: 14332T
_________ Lighthouse Academy
Agency ID: 73216K
_________ Sunrise Education Center
Agency ID: 5650M
_________ Summit Academy
Agency ID: 13917H
_________ Summit Academy North
Agency ID: 80346M
_________ All other CSP Mgt/MEP Services
Agency ID: 9944A
Reason Fingerprinted: SE - School Employment, mcl 380.1230
MEP Services, 2120 Progressive Dr., Hartland, MI 48353
Phone: 810-632-6863

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