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

Electronic Fingerprinting Form - Florida Board Of Osteopathic Medicine Page 4

Fingerprinting information page 4 of 4

Confirmation of Receipt of:



SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES,



RETENTION OF FINGERPRINTS,



RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD

Name: _________________________________________________ File # (if known) ___________________

Profession: ____________________________________

Date of Birth: _______________

(MM/DD/YYYY)

Other last names: __________________________________________________________

I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing,

retention, privacy and right to challenge incorrect criminal history records and the “Privacy Statement” document from the

Federal Bureau of Investigation.

□

Yes

Signature: _______________________________________

Date: ______________

(MM/DD/YYYY)

Please send this form with your application and fees to:

Board of Osteopathic Medicine

P.O. Box 6330

Tallahassee, FL 32314-6330

If you send this form separate from your application please mail it to:

Board of Osteopathic Medicine

4052 Bald Cypress Way

Bin # C06

Tallahassee, FL 32399-3256

DH-MQA 1029, Revised 11/12

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

Electronic Fingerprinting Form - Florida Board Of Osteopathic Medicine Page 4