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L.A.W. Livescan Consultant, LLC

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Livescan Pre Registration Application

APPLICANT INFORMATION

Please type or print legibly.

First name*

Middle Name

Last name*

Date of Birth*

Gender:*

Social Security Number:

Weight in lbs.*

Height in ft. in.*

Hair Color:*

Eye Color:*

Race / Ethnicity*

Place of Birth (State or Country) :*

Citizenship:*

Current Address

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone Number:

Email Address:*

Driver’s License Number:

REASON FOR REQUEST

INDIVIDUAL

LEAVE BLANK / DO NOT COMPLETE / STOP HERE

Please select one of the following:

Gold Seal/Adoption (Enter Authorization Number if applicable)

Gold Seal/Letter/VISA

Immigration/VISA Individual Challenge

Individual Review

Attorney/Client (Written Authorization Required)

Mailing Information:

Mailing Information:

Country/Region

Address

City

Zip / Postal code

AGENCY

Please select from the following (*ORI Required):*

Adult Dependent Care

Child Care

Criminal Justice

Government Employment

Government Licensing or Certification

Private Party Petition

Public Housing

Maryland State Police Licensing

Agency Authorization Number:

ORI Number:*

Position Applied:*

Attach ID*

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