Fingerprint Submission Authorization Form (Page 2 of 3) in pdf

Fingerprint Submission Authorization Form Page 2

Skin Tone

Ethnic Origin (Enter either Hispanic or Non-Hispanic)

 Albino

Light

Ruddy

Black

Light Brown

Sallow

Dark

Medium

Yellow

Dark Brown Med Brown

Other

Fair

Olive

Unknown

Weight (enter whole numbers only)

Height (enter feet and inches)

Driver’s License State

Driver’s License Number

Street Address

City

State

Zip

County

Country

Applicant Type: Check appropriate response (check only one)

Direct Service Provider

Operator

Family Care

Volunteer

Aliases (this includes maiden name)

Last Name

First Name

Middle Name

Suffix

Position: Choose the appropriate type (check only one)

Administration

Food Service

Other Support

Rehabilitation

Other Support

Housekeeping

Physician-non-Psychiatric Research

Direct Care

 Intensive Case Mgmt

Psychiatry

Residential Care

Clinical Ancillary Services  Maintenance & Engineering Psychology

Safety

Clinical Mgmt

 Nursing

Quality Assurance

Social Work

 New Hire

Justice Center/OASAS Waiver

Yes

No

 Transfer from other Provider/Program/Agency

Program Code (enter four digit code from Page 3)

Job Duties: Please enter detailed information about the job duties that indicate how the applicant will have direct

and substantial unsupervised contact with persons receiving services/care and to what degree. (150 Character

limit)

User Department Division – Please enter the name of the DDSO, agency or registered provider with which the

applicant will be associated.

____________________________________________________

DDSO/Agency/Registered Provider Name

Fingerprint Submission Authorization Form Page 2

Related Articles

Related forms

Related Categories