Electronic Fingerprinting Form - Florida Board Of Osteopathic Medicine


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:
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);
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: ___________________
Date of Birth: _________________ Place of Birth: _______________________________________________
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.


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