Electronic Fingerprinting Form - Florida Board Of Osteopathic Medicine printable pdf download

Fingerprinting information page 1 of 4

Electronic Fingerprinting

Take this form with you to the Live Scan service provider. Please check the service provider’s

requirements to see if you need to bring any additional items.



Background screening results are obtained from the Florida Department of Law Enforcement and the

Federal Bureau of Investigation by submitting to a fingerprint scan using the livescan method;



You can find a Livescan service provider at:

regulation/background-screening/index.html;



Failure to submit background screening will delay your application;



Applicants may use any Livescan service provider approved by the Florida Department of Law

Enforcement to submit their background screening to the department;



If you do not provide the correct Originating Agency Identification (ORI) number to the livescan service

provider the Board office will not receive your background screening results;



You must provide accurate demographic information to the livescan service provider at the time your

fingerprints are taken, including your Social Security number (SSN);



EDOH2015Z;

The ORI number for the Board of Osteopathic Medicine is



Typically background screening results submitted through a Livescan service provider are received by

the Board within 24-72 hours of being processed.



If you obtain your livescan from a service provider who does not capture your photo you may be

required to be reprinted by another agency in the future.

Name:___________________________________________ Social Security Number: ___________________

Aliases:_________________________________________________________________________________

Date of Birth: _________________ Place of Birth: _______________________________________________

(MM/DD/YYYY)

Citizenship: __________________ Race: ________

(W-White/Latino(a); B-Black; A-Asian;

NA-Native American; U-Unknown)

Sex: ______________

Weight: _________

Height: _______________

(M=Male; F=Female)

Eye Color:___________ Hair Color: _________________________

Address: ______________________________________________________ Apt. Number: ____________

City:_____________________________________________ State: _____________ Zip Code: __________

Transaction Control Number (TCN#):________________________________________

(

This will be provided to you by the Live Scan Service provider.)

Keep this form for your records.

DH-MQA 1029, Revised 11/12

Rule 64B15-12.003, F.A.C.

Electronic Fingerprinting Form - Florida Board Of Osteopathic Medicine

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