Electronic Fingerprinting Form - Florida Board Of Osteopathic Medicine (Page 3 of 4) in pdf

Fingerprinting information page 3 of 4

US Department of Justice, Federal Bureau of Investigation,

Criminal Justice Information Services Division

Privacy Statement

Authority: The FBI’s acquisition, preservation and exchange of information requested by this form is generally authorized

under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include numerous Federal

statutes, hundreds of State statutes pursuant to Pub.L.92-544, Presidential executive orders, regulations and/or orders of

the Attorney General of the United States, or other authorized authorities. Examples include, but are not limited to: 5

U.S.C. 9101; Pub.L.94-29; Pub.L.101-604; and Executive Orders 10450 and 12968. Providing the requested information

is voluntary; however, failure to furnish the information may affect timely completion of approval of your application.

Social Security Account Number (SSAN): Your SSAN is needed to keep records accurate because other people may

have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is

responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your

SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal Agencies to use this number

to help identify individuals in agency records.

Principal Purpose: Certain determinations, such as employment, security, licensing and adoption, may be predicated on

fingerprint based checks. Your fingerprints and other information contained on (and along with) this form may be

submitted to the requesting agency, the agency conducting the application investigation, and/or 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. During the processing of this application, and for as long hereafter as my be relevant to the activity for which

this application is being submitted, the FBI( may disclose any potentially pertinent information to the requesting agency

and/or to the agency conducting the investigation. The FBI may also retain the submitted information in the FBI’s

permanent collection of fingerprints and related information, where it will be subject to comparisons against other

submissions received by the FBI. Depending on the nature of your application, the requesting agency and/or the agency

conducting the application investigation may also retain the fingerprints and other submitted information for other

authorized purposes of such agency(ies).

Routine Uses: The fingerprints and information reported on this form may be disclosed pursuant to your consent, and may

also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b)) and

all applicable routine uses as many be published at any time in the Federal Register, including the routine uses for the FBI

Fingerprint Identification Records System (Justice, FBI-009) and the FBI’s Blanket Routine Uses (Justice/FBI-BRU).

Routine uses include, but are not limited to, disclosures to: appropriate governmental authorities responsible for civil or

criminal law enforcement counterintelligence, national security or public safety matters to which the information may be

relevant; to State and local governmental agencies and nongovernmental entities for application processing as authorized

by Federal and State legislation, executive order, or regulation, including employment, security, licensing, and adoption

checks; and as otherwise authorized by law , treaty, executive order, regulation, or other lawful authority. If other agencies

are involved in processing the application, they may have additional routine uses.

Additional Information: The requesting agency and/or the agency conducting the application investigation will provide you

additional information pertinent to the specific circumstances of this application, which may include identification of other

authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the

Federal Executive Branch has also published notice.

DH-MQA 1029, Revised 11/12

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

Electronic Fingerprinting Form - Florida Board Of Osteopathic Medicine Page 3