Fillable MARYLAND Department of Health 4201 Patterson Avenue, Baltimore, (State of Maryland)

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MARYLAND Department of Health 4201 Patterson Avenue, Baltimore, (State of Maryland)

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Page 1 of 2
MD-BSWE – LIVESCAN PRE-REGISTRATION APPLICATION – 2021
MARYLAND
Department of Health
LBSW & LGSW BY EXAMINATION
CJIS – CRIMINAL JUSTICE INORMATION SYSTEM
AND
CHRC – CRIMINAL HISTORY RECORDS CHECK
I FOR APPLICANTS WHO RESIDE IN MARYLAND:
1) LIVESCAN PRE-REGISTRATION FORM – LOCATED ON THE NEXT PAGE
2) TAKE THIS FORM TO A FINGERPRINTING LOCATION IN MARYLAND
3) DO NOT MAIL THIS FORM TO THE BOARD OF SOCIAL WORK
4) DO NOT SEND ANY RECEIPTS TO THE BOARD OF SOCIAL WORK
5) THE BOARD RECEIVES THE CHRC ELECTRONCIALLY AND DIRECTLY FROM CJIS
FOR FAST AND ACCURATE SERVICE
1. If you are requesting a background check for licensing purposes you must use the Maryland
Board of Social Work Examiner’ name and authorization numbers, listed below:
CJIS #1300005486 & FBI ORI – MD920513Z
2. If your background check is being sent to a government agency you may also need an ORI
number.
3. You must bring a valid form of government identification. (Examples: driver's license,
Certificate of Naturalization, passport, Alien Registration Card, or Military Identification)
4. Take the Livescan Pre-registration Application to any fingerprinting center.
5. Bring payment: major credit cards, checks, and money orders are accepted. Cash is not
accepted at the State Operated Fingerprinting Centers.
Government Operated Services: The fee is $31.25 for a full background check State and FBI.
Commercial Fingerprinting Services (Private Providers): The fee is $30.00 plus an additional
amount set by the private provider.
For a listing of providers, both State and Private please go to
https://www.dpscs.state.md.us/publicservs/bgchecks.shtml
II FOR APPLICANTS WHO DO NOT RESIDE IN MARYLAND:
1) Send an Email message, mdh.socialwork@maryland.gov
2) Provide your legal name and mailing address.
3) A fingerprint card will be mailed to you with an envelope addressed to CJIS.
4) DO NOT MAIL THE COMPLETED FINGERPRINT CARD TO THE BOARD
MARYLAND BOARD OF SOCIAL WORK EXAMINERS
4201 Patterson Avenue, Baltimore, Maryland 21215 – 2299 www.health.maryland.gov/bswe/
Phone Number: 410-764-4788 Fax Number: 410-358-2469 Toll Free: 1-877-526-2541
Page 2 of 2
MD-BSWE – LIVESCAN PRE-REGISTRATION APPLICATION – 2021
DO NOT MAIL
T
HE FORM ON THE NEXT PAGE
TO THE BOARD
PRINT OUT THE FORM
C
OMPLETE IT
TAKE IT WITH YOU
T
O A FINGER PRINTING PROVIDER
For a listing of providers, both State and Private please go to
https://www.dpscs.state.md.us/publicservs/bgchecks.shtml
ITCD-16 LIVE-SCAN PRE-REGISTRATION APPLICATION Jan 2022
STATE OF MARYLAND
D
EPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
I
NFORMATION TECHNOLOGY AND COMMUNICATIONS DIVISION
C
RIMINAL JUSTICE INFORMATION SYSTEM - CENTRAL REPOSITORY (CJIS-CR)
LIVESCAN PRE-REGISTRATION APPLICATION
APPLICANT INFORMATION
Please type or print legibly.
Name:
Date of Birth:
Social Security Number:
Gender:
Male Female
Height:
ft. in.
Weight:
Eye Color:
Hair Color:
Race/Ethnicity:
Black White Asian/Pacific Islander Native American Other
Place of Birth:
Citizenship:
Street Address:
City:
State:
Zip Code:
Phone Number:
Driver’s License Number:
Email Address:
REASON FOR REQUEST
INDIVIDUAL
Please select one of the following:
Gold Seal/Adoption (Enter Authorization Number if applicable) ______________________________________
Gold Seal/Letter/VISA
Immigration/VISA
Individual Challenge
Individual Review
Attorney/Client (Written Authorization Required)
Mailing Information:
Name:
Street Address:
City:
State:
Zip Code:
AGENCY
Please select from the following (*ORI Required):
Adult Dependent Care
Child Care*
Criminal Justice*
Government Employment*
Government Licensing or Certification*
Maryland State Police Licensing*
Private Party Petition**
Public Housing
Agency Authorization Number:
*ORI Number:
**Position Applied:
1300005486
MD920513Z
SOCIAL WORK LICENSE
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MARYLAND Department of Health 4201 Patterson Avenue, Baltimore, (State of Maryland)

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Completed 15 March 2022

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