Fillable Louisiana State Nursing Board Fingerprint Authorization (Delgado Community College)

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Louisiana State Nursing Board Fingerprint Authorization (Delgado Community College)

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LOUISIANA STATE BOARD OF NURSING
17373 Perkins Road
Baton Rouge, Louisiana 70810
Telephone (225) 755-7500 Fax: (225) 755-7580
www.lsbn.state.la.us
FINGERPRINT INSTRUCTIONS
APPLICATION FOR PERMISSION TO ENROLL IN CLINICAL NURSING COURSES OR
FOR INITIAL LICENSURE BY EXAMINATION MUST BE ACCOMPANIED BY
FINGERPRINT CARDS AND FEE AS FOLLOWS:
1. Complete and sign the Authorization for Criminal Background Check (CBC) form.
* Please copy each page of the Authorization for Criminal Background Check (CBC) form
on front of separate page.
DO NOT PRINT DOUBLE SIDED
You may obtain cards at Law Enforcement Agencies. However, the Cards must have
demographics on the front.
OUT OF STATE EXAM APPLICANTS -- You may download the forms from LSBN
website under “EDUCATION” and request cards from LSBN or obtain cards at Law
Enforcement Agencies. However, the Cards must have demographics on the front.
2. Contact your campus security or local police/sheriff’s office, or an office of the state police to
inquire about procedures for completion of fingerprint cards. They may specify a particular
location, time and fee for fingerprinting. Take both cards to the designated location.
•
Each of the two (2) FBI cards need a separate and distinct set of your fingerprints. If the
agency utilizes an electronic scan system, request that they scan your fingerprints and print
the first FBI card, then scan your fingerprints again and print the second FBI card.
•
If you’ve experienced problems in the past with fingerprinting or obtaining a CBC report,
advise the officer/technician before they print you. The following suggestions may improve
print quality:
Hands must be clean and dry. Wash your hands vigorously with warm water and dry
thoroughly immediately prior to being fingerprinted.
If hands are very dry or cracked, wash hands and apply a touch of moisturizer onto
fingertips, removing any excess lotion with paper towel prior to being fingerprinted. This
may help raise the ridges for printing.
*MUST HAVE 2 DIFFERENT FINGERPRINTS- DO NOT SUBMIT 2 COPIES
OF SAME PRINT.
3. Return the two (2) completed cards, required fee and authorization forms to the office of your
program head. Do not fold or staple the cards.
4. Fee for fingerprint record check is $40.75 by money order made payable to the Louisiana State
Board of Nursing.
5. The criminal history record information checks are authorized under the Nurse Practice Act,
Louisiana Revised Statutes 37:920.1 and are required as part of the permission to enroll in
clinical nursing courses process.
6. The permission to enroll may not be delayed awaiting these reports; however, future action may
result if the criminal history record information so indicates.
Revised Updated: 2/19/2008 02/07/2011. 9/8/11, 2/9/12, 1/5/15, 1/22/16, 7/25/16PAD
AUTHORIZATION FOR CRIMINAL BACKGROUND CHECK (CBC) – PAGE I
**FORMS MUST BE FILLED OUT IN INK AND BE REVIEWED BY SUBMITTING AGENCY/INDIVIDUAL FOR ACCURACY**
****FINGERPRINTS ARE NECESSARY FOR A POSITIVE IDENTIFICATION****
FEES FOR CBC: (money order or bank cashier’s check)
► $40.75 –Payable to Louisiana State Board of Nursing for State/FBI fingerprint card processing
-OR-
► $50.75 – Payable to Louisiana State Board of Nursing for State/FBI fingerprint cards and
utilization
of live scan fingerprinting system at LSBN (Registered Nurses only).
____________________________________________________________________________________________________________________________________________________________________________________
****PLEASE PRINT****
Louisiana State Board of Nursing Patricia A. Dufrene MSN, RN
FACILITY OR AGENCY FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE\
Cynthia York MSN, CGRN
FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE\
17373 Perkins Road
MAILING ADDRESS SIGNATURE OF (1) AUTHORIZED REPRESENTATIVE
Baton Rouge, LA 70810 (225) 755-7500
CITY STATE ZIP CODE FACILITY OR AGENCY PHONE NUMBER
Request For: (pick one only)
□ ALCOHOL AND BEVERAGE COMMISSION
□ ALCOHOL BEVERAGE OUTLET
□ CASA
□ CONCEALED HANDGUNS
□ CRIMINAL JUSTICE EMPLOYEE
□ DAYCARE
□ DENTISTRY BOARD
□ DEPARTMENT OF LABOR
□ DEPARTMENT OF PUBLIC SAFETY
□ EMPLOYERS
□ FIREFIGHTERS
□ GAMING
□ HEALTH CARE PROVIDER
□ IMMIGRATION
□ JUVENILE DETENTION CENTER
□ DEPARTMENT OF INSURANCE
□ MANUFACTURED HOUSING
□ MEDICAL EXAMINERS
□ OCS FOSTER/ADOPTIVE
□ OCS PERSONNEL
□ OFFICE OF FINANCIAL INSTITUTIONS
□ OFFICE OF PUBLIC HEALTH
□ PHARMACY BOARD
□ POSTSECONDARY EDUCATION
□ PRACTICAL NURSING
□ PRIVATE ADOPTION
□ PRIVATE INVESTIGATORS
□ PRIVATE SECURITY
□ PUBLIC HOUSING
□ PUBLIC TAG AGENT
REGISTERED NURSING
□ RELIGIOUS ACTIVISTS
□ RIVERBOAT PILOTS
□ SCHOOL
□ SENATE AND GOVERNMENTAL AFFAIRS
□ TAXI DRIVERS
□ USED MOTOR VEHICLE COMMISSION
□ VOLUNTEERS WITH YOUTH SERVING
ORGANIZATIONS
****Please Print all but Signature****
APPLICANTS FULL NAME: ______________________________________________________
****PRINT – USE INK**** LAST FIRST MIDDLE
{INCLUDE MAIDEN NAME & PREVIOUS MARRIED NAMES IF APPLICABLE}
APPLICANTS SIGNATURE: ______________________________________________________
APPLICANTS SOCIAL SECURITY # _ _ _ - _ _ - _ _ _ _ DATE OF BIRTH: _ _ / _ _ / _ _
DRIVERS LICENSE #____________________& STATE ______ RACE ____ SEX ____
POSITION OR LICENSE APPLIED FOR ________________________________
RN
AUTHORIZATION FOR CRIMINAL BACKGROUND CHECK (CBC) – PAGE II
AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION
By my signature above, I hereby authorize the Louisiana State Police to release all pertinent criminal record information
maintained in their files, other states files, or the FBI files (if applicable), which may confirm or deny my eligibility with
the facility or agency named above.
APPLICANT PROCESSING-DISCLOSURE
BUREAU OF CRIMINAL IDENTIFICATION AND
INFORMATION
P.O. BOX 66613 (MAIL SLIP A-6)
LSPAPPR/R8.03
LOUISIANA STATE BOARD OF NURSING NOTICE:
AGENCY PLEASE PRINT OR TYPE INFORMATION,
EXCLUDING ADMINISTRATORS OR
AUTHORIZED PERSON SIGNATURE.
INCOMPLETE FORMS WILL NOT
BE
PROCESSED.
17373 Perkins Road
MAILING ADDRESS
Baton Rouge LA 70810
CITY STATE ZIP CODE
/ /
/
NAME DATE OF BIRTH RACE SEX
SOCIAL SECURITY NUMBER
ALL INFORMATION RELEASED MUST REMAIN STRICTLY CONFIDENTIAL AND ONLY
THOSE AUTHORIZED BY LAW TO RECEIVE THIS INFORMATION MAY SUBMIT A REQUEST.
DO NOT WRITE BELOW THIS LINE: (FOR BUREAU OF CRIMINAL IDENTIFICATION AND INFORMATION USE ONLY
NOTICE:
The response to your request for a criminal history check is based on a review of the State of
Louisiana’s criminal history records database as is available at the time of request. This does not preclude the possible
existence of conviction information not available in our database.
CRIMINAL HISTORY DETERMINATION
:
RAPSHEET ATTACHED
RESPONSE BELOW
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Louisiana State Nursing Board Fingerprint Authorization (Delgado Community College)

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Completed 26 July 2020

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