IN STATE LICENSING APPLICANT
Texas Department of Insurance
This document is your FAST Fingerprint Pass for a state and national criminal history record check. Please schedule a
fingerprint appointment by visiting
or by calling 1-888-467-2080. When scheduling an
appointment you will be prompted by IdentoGO for the following additional personal data: Date of Birth, Sex,
Race, Ethnicity, Skin Tone, Height, Weight, Eye Color, Hair Color, Place of Birth and Home Address. During
your Fingerprint appointment you will also be prompted for Social Security Number and Driver License
Number. Requested data is required by the Texas Department of Public Safety to process your background
check. These data elements have been omitted from this document in order to better protect the security of your
personal information. You may pay for FAST services online with a credit card or onsite with a check or money order only. Your fingerprints will be
submitted to the Texas Department of Public Safety and the Federal Bureau of Investigation.
Select: Insurance Licensing
Follow the prompts to enter requested information.
Select: Online Scheduling
Bring this completed form with you to your appointment.
Select: English or Espanol
Enter: First and Last Name
Section One: Qualified Entity Information
RFP: Government Code 411.106
(If resubmission for rejected fingerprints)
Agency/Entity/Organization Name: _Texas Department of Insurance
Section Two: Applicant Name (To be completed by applicant)
Section Three: Waiver Information (To be completed and signed by applicant)
I certify that all information I provided in relation to this criminal history record check is true and accurate. I authorize the Texas Department of Public
Safety (DPS) to access Texas and Federal criminal history record information that pertains to me and disseminate that information to the designated
Authorized Agency or Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer, through the DPS Fingerprint-based
Applicant Clearinghouse of Texas and as authorized by Texas Government Code Chapter 411 and any other applicable state or federal statute or policy.
I authorize the Texas Department of Public Safety to submit my fingerprints and other application information to the FBI for the purpose of comparing the
submitted information to available records in order to identify other information that may be pertinent to the application. I authorize the FBI to disclose
potentially pertinent information to the DPS during the processing of this application and for as long hereafter as may be relevant to the activity for which
this application is being submitted. I understand that the FBI may also retain my fingerprints and other applicant information in the FBI’s permanent
collection of fingerprints and related information, where all such data will be subject to comparisons against other submissions received by the FBI and
to further disseminations by the FBI as may be authorized under the Federal Privacy Act (5USC 552a(b)). I understand I am entitled to obtain a copy of
any criminal history record check and challenge the accuracy and completeness of the information before a final determination is made by the Qualified
Entity. I also understand the Qualified Entity may deny me access to children, the elderly, or individuals with disabilities until the criminal history record
check is completed. If a need arises to challenge the FBI record response, you may contact the agency that submitted the information to the FBI, or you
may send a written challenge request to the FBI's Criminal Justice Information Services (CJIS) Division at FBI CJIS Division, Attention: Correspondence
Group, 1000 Custer Hollow Road, Clarksburg, WV 26306.
Section Four: Service Center Information (To be completed by FAST Enrollment Agent)
Date Prints Taken _______________________
Amount Charged For Service: _$39.70_
Billing Acct _____________________________________________________
I HAVE COMPARED THE GOVERNMENT-ISSUED IDENTIFICATION PRESENTED BY THE APPLICANT AND ATTEST THAT TO MY BEST
DETERMINATION; I HAVE FINGERPRINTED THE SAME PERSON.
E.A. Name: ________________________________________________
E.A. Signature: ________________________________________________