In State Applicant - Texas Medical Board printable pdf download

IN STATE APPLICANT

TEXAS MEDICAL BOARD

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.

Logon to

Select: Select: Physician Licensing

Select: Texas

Enter: MB - ______________

Select: Online Scheduling

Follow the prompts to enter requested information.

Select: English or Espanol

Bring this completed form with you to your appointment.

Enter: First and Last Name

Section One: Qualified Entity Information

ORI#:

TX920350Z

Applicant ID: __MB - __________

Original TCN: ________________________________________

(If resubmission for rejected fingerprints)

Agency/Entity/Organization Name: _________Texas Medical Board___________________________________________________

Section Two: Applicant Name (To be completed by applicant)

Last: ______________________________________

First: _________________________________

Middle: ________________________

(Please print)

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.

Signature: ______________________________________________________

Date: __________________________________________

Section Four: Service Center Information (To be completed by FAST Enrollment Agent)

Date Prints Taken _______________________

Amount Charged For Service: __$41.45___

 Check

 Money Order

 Visa

 MasterCard

 Billing Acct _____________________________________________________

Paid by: