Clear Form
LIVESCAN FINGERPRINT REQUEST
Date fingerprinted: __________ Type of picture ID presented: ___________
APPLICANT INFORMATION
Must provide a picture ID to be printed
Applicant Name _______________________________________________
Last, first, middle
Date of Birth ____________
Race ______
Sex ______
Applicant address ______________________________________________ ___________________________________Zip ________ Applicant phone number _________________________________________
REQUESTING AGENCY INFORMATION
Agency ID: 1340A
(RQID)
Agency Name: Bureau of Regulatory Services
Reason fingerprinted:
ARDepartment of State, Bureau of Regulatory Services
**Disclaimer: Any and all fingerprints processed with incorrect fingerprint codes/reasons, etc are the responsibility of the REQUESTING AGENCY. MSP will charge for second requests due to incorrect fingerprint reason.
L-1 Identity Solutions 1-800-377-2080 www.L1id.com