Fingerprint Submission Authorization Form printable pdf download

NYS Justice Center for the

Protection of People with

Special Needs (Justice

Center)

Fingerprint Submission

Criminal Background

Check Unit

Authorization Form

161 Delaware Avenue

Delmar, NY 12054

Email:

cbc@JusticeCenter.ny.gov

This form provides NYS Division of Criminal Justices Services (DCJS) the information necessary to

process the fingerprints that are submitted. The information is required when using LIVESCAN or

when scanning prints from fingerprint cards. The form must be completed prior to presentation to the

LIVESCAN operator, however, the operator will confirm that information on the form matches the

physical attributes of the applicant and may change the information to reflect actual physical attributes.

The LIVESCAN operator MUST confirm the identification of the applicant by means of one of the

following documents which includes a photograph: valid driver’s license, valid school identification

document, valid passport, or valid military identification. If one of these is not available, documents

that can confirm identity for employment purposes can be utilized. If “ink and roll” is being used the

individual taking the prints must confirm the identification of the applicant.

Instructions:

1. Complete all fields on the form. Please print legibly.

2. If Livescan prints are being taken, give completed form to applicant to bring to Livescan location.

3. If “ink and roll” is being used, mail the completed form along with fingerprint cards and JC Fingerprint

Submission Form to the JC CBC Unit at PO Box 3005 Schenectady, NY 12303-0005.

Applicant

Last Name

First Name

Middle Name

Suffix

Social Security Number

Date of Birth

Birth State

Birth Country

Citizenship

Alien Registration # if applicable

Gender:

Male

Female

Race: Check the code which best describes the person.



W (white)

B (black)



I (American Indian or Alaskan Native)

A (Asian or Pacific Islander)



U (Unknown)

O (Other)

Eye Color: Check the eye color code which best describes the person’s eye color.

BLK – Black

GRY – Gray

MAR – Maroon

XXX – Unknown

BLU – Blue

GRN – Green

PNK – Pink

MUL – Multi-color

BRN – Brown

HAZ – Hazel

Hair Color: Check the hair color code which best describes the person’s hair color.

BAL – Bald

BRO – Brown

SDY – Sandy

BLU – Blue

BLK – Black

GRY – Gray

WHI – White

GRN – Green

BLN – Blonde

RED – Red

XXX – Unknown

ONG – Orange

PNK – Pink

PLE – Purple

Fingerprint Submission Authorization Form

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