Fingerprinting Request for a Background Check via Electronic Fingerprinting BCI FBI BCI & FBI Type of Photo ID & ID # Name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone NumberDate of Birth MM slash DD slash YYYY SSN Complete this portion only if an FBI background check is needed:Sex Race Height Weight Eyes Hair Reason For BackgroundCheckFBI Reason Code BCI Reason Code Mail results to: Company Name Attn Name First Last Phone NumberAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Direct Copy to Ohio Dept. of Public Safety BMV Dealer License Ohio State Racing Commission OH Veterinary Medical Licensing Bd Ohio Pharmacy Board Ohio Dept. of Education Ohio Dept. of Liquor Control BMV Deputy Registrar Ohio Dept. of Insurance OPOTA Social Work Board Ohio Board of Nursing State Speech and Hearing Professionals Bd Child Care Ctr-Type A-ODJFS Lottery Commission Ohio Construction Board State Vision Professionals Board I certify that the personal identifiers provided on this form are accurate and I voluntarily and knowingly authorize the Ohio Bureau of Criminal Investigation and/or the Federal Bureau of Investigation to conduct a criminal records check for the information relating to me. I also voluntarily and knowingly authorize BCI to disseminate criminal conviction and juvenile delinquency adjudication records toSignature I voluntarily and knowingly release and discharge the Ohio Attorney General's Office, BCI, the FBI a and their employees from all claims and liability related to this authorized criminal record review and dissemination.Applicant's Name First Last Witness Name First Last Applicant's SignatureWitness SignatureParent/Guardian Name First Last Parent/Guardian Signature (Minor Applicants Only)By signing this form the applicant acknowledges that all information on this form is accurate. Any mistakes or errors on this form are the responsibility of the applicant.CAPTCHA