RI-030 (01/2019)
Michigan State Police
AUTHORITY: MCL 28.162, MCL 28.214, MCL 28.248, & MCL 28.273
COMPLIANCE: Voluntary. However, failure to complete this form will
result in denial of request.
LIVE SCAN FINGERPRINT BACKGROUND CHECK REQUEST
Purpose: To conduct a civil fingerprint-based background check for employment, to volunteer, or for licensing purposes as authorized by law.
Instructions: See page two.
I. Authorizing Information
1. Fingerprint Reason Code 2. Requestor/Agency ID 3. Agency Name 4. Individual ID (MNU-OA)
LL 1479J
MI Dept of Licensing & Regulatory Affairs - Liquor Control
II. Applicant Information:
Type or clearly print answers in all fields before going to be
fingerprinted.
1a. Last Name 1b. First Name 1c. Middle Initial 1d. Suffix
2. Any Alternative Names, Last Names, or Aliases 3. Social Security Number (Optional)
4. Place of Birth (State or Country) 5. Date of Birth 6. Phone Number 7. Driver's License / State ID Number 8. Issuing State
9. Home Address 10. City 11. State 12. ZIP Code
13. Sex 14. Race 15. Height 16. Weight 17. Eye Color 18. Hair Color
III. Live Scan Information
1. Date Printed 2. Picture ID Type Presented 3. Transaction Control Number (TCN) 4. Live Scan Operator*
* When an individual ID is provided, please enter the ID into the Miscellaneous Number (MNU) field on the Live Scan device. Select OA
-
Originating
Agency Identifier and then enter the unique identifier in the Identification Code field.
IV. Privacy Act Statement
Authority: Acquisition, preservation, and exchange of fingerprints and associated information by the Federal Bureau of Investigation
(FBI) is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include
Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your
fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on
fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing,
investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in
the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint
repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your
fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints
may continue to be compared against other fingerprints submitted to or retained by NGI.
Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated
information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed
without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the
Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine Uses include, but are
not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment,
contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement
agencies; criminal justice agencies; and agencies responsible for national security or public safety.
V. Procedure to Obtain a Change, Correction, or Update of Identification Records
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes
changes, corrections, or updating of the alleged deficiency; he/she should make application directly to the agency which contributed
the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any
entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D2, 1000 Custer Hollow
Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency
to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the
original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that
agency. (28 CFR § 16.34)
VI. Consent
I understand that my personal information and biometric data being submitted by Live Scan, will be used to search against
identification records from both the Michigan State Police (MSP) and the FBI for the purpose listed above. I hereby authorize the
release of my personal information for such purposes and release of any records found to the authorized requesting agency listed
above.
Signature: Date:
