1) WHAT IS THE REASON FOR THE BACKGROUND CHECK (customer is required to provide this information):
X GETTING A LICENSE/PERMIT
2) Please provide the specific Ohio Revised Code (ORC) you need to be processed with: O.R.C.#_________
(Print clearly; illegible writing will delay delivery)
3) APPLICANT INFORMATION:
Name: ___________________________________________ SS Number: ________ - ______ - _________
Address: __________________________________________ Date of Birth: _________________________
City, State, Zip: ____________________________________ Race:_________________________________
Gender:____________________________________________ Height:________________________________
Weight:____________________________________________ Hair Color:_____________________________
Eye Color:__________________________________________ Email: ___________________________________
Daytime Phone Number: (_______) ________-___________ How did you hear about us? ___________________
***If you have already gotten your fingerprints done at a Fast Fingerprints location, your results will go electronically to
the Medical Board, and a mailed copy will come back to you at your home address***
4) Company/Agency Name: ________Ohio State Medical Board____________________________________________
Address: _______30 E. Broad Street 3
rd
Floor______________ Attn: __Krista Tackett____________________
City, State, Zip: __Columbus, OH, 43215______________________ Phone: (_614__) _466___-_3934____
***If you are going to be sending in fingerprint cards, please send this completed form along with your cards to:
Fast Fingerprints
Ohio Card Scanning Division
1486 Bethel Rd.
Columbus, OH, 43220
***If you went to a Fast Fingerprints location and had fingerprints taken electronically, please fax or email this form to:
614-635-2879
contactus@fastfingerprints.com
RELEASE OF BACKGROUND CHECK RESULTS
I hereby certify that I have given National Background Check, Inc. permission to obtain all criminal history information pertaining to me in the files of the
Ohio Bureau of Criminal Identification and Investigation (BCI&I), the Federal Bureau of Investigation (FBI) (if requested), and release that information to
the company/agency /individual indicated above. By placing my fingerprint images on the WEBCHECK Scanner, I am authorizing BCI&I to release
criminal history information about me to National Background Check, Inc. and the company/agency /individual indicated above. I hereby release BCI&I and
any and all individuals connected therewith from all liability in connection with the dissemination of such criminal history information. I understand National
Background Check, Inc. cannot guarantee that my fingerprint images will be deemed readable by BCI&I, in which case I may need to be re-fingerprinted. I
understand this does NOT constitute a refund due to charges incurred by BCI&I immediately after the data is transmitted. National Background Check, Inc.
will assist me with the process to complete this background check if I am rejected a second time.
I understand that using the WEBCHECK System returns a “no hit” (those containing no criminal history) result within (10) business days or sooner or a
“mailed” result (those that contain a criminal arrest history) could take up to (30) thirty business days before being forwarded to the requested destination.
Applicant Signature: ________________________________________ Date: _____/_____/_____
OHIO STATE MEDICAL BOARD FORM
REQUESTED BACKGROUND CHECK
BCI&FBI $72.00
This registration form completed and signed is the official document of the transaction. All
information collected and received during the process of fingerprinting and dissemination of
background check results is kept confidential and meant for National Background Check,
Inc. (NBCI) use only. This form MUST be submitted to us in order to copy your fingerprints.
❖ PAYMENT METHOD:
❑ CHECK #: _____________ (IF PAYING BY CHECK ~ MAIL THIS FORM AND CHECK PAYMENT TO): NBCI
1486 BETHEL ROAD
COLUMBUS, OHIO 43220
❑ CREDIT CARD (IF PAYING BY CREDIT CARD ~ FAX OR EMAIL THIS FORM IF YOU ARE NOT COMFORTABLE PROVIDING THIS PAYMENT INFO. VIA
FAX/EMAIL, PLEASE CONTACT NBCI CORPORATE TO PAY OVER THE PHONE AT (614) 457-8900 OR (877) 932-2435 AND A REPRESENTATIVE CAN ASSIST YOU.
(VISA, MC, AMEX): ____________ CREDIT CARD #:____________________________________________________________________________
EXP. DATE: ______/______CVV CODE: __________ NAME AS IT APPEARS ON CARD: _________________________________________________________________
AUTHORIZED SIGNATURE: ______________________________________________________________________________________
I AUTHORIZE NBCI TO CHARGE MY CREDIT CARD TO PAY FOR THE ABOVE BACKGROUND CHECK.
FOR OFFICE USE ONLY: Date Received: ________ Processed By: _______ Date Processed: ________
