Rev January 2021
Marijuana Program Fingerprint Verification Form
This form is to be completed by the fingerprint technician taking your fingerprints to submit as part of the Arizona Marijuana
Program Dispensary Agent, Lab Agent, Facility Agent, Designated Caregiver, or Minor Caregiver (Custodial Parent/Legal
Guardian) application.
At
tention Fingerprint Technician
Please follow the instructions below for fingerprinting this applicant:
1. Please fill out or ensure that the applicant has filled out all of the required boxes on the fingerprint cards prior to taking the
fingerprints.
2. Request a valid, unexpired government-issued photo ID from the applicant and compare the physical descriptors on the
applicant’s photo ID to the applicant and to the information on the fingerprint cards.
3. Fill out the information in the boxes below. Please print clearly.
4. Once the prints have been taken:
• Place the fingerprint cards and this form into the envelope and seal it.
• Please sign your name across the edge of the seal.
• Return the sealed envelope to the applicant.
*DO NOT give the applicant the fingerprint card without first sealing it inside the envelope and signing
across the edge of the seal.
PRI
NT/TYPE the following information, and SIGN your name:
First and Last Name of Applicant
Applicant ADHS Licensing Portal Email Address
Type of Photo ID provided (check one)
Driver’s License/MVD Issued State ID #
Passport #
Other (please specify)
Fingerprint Technician Information
Fingerprint Technician Signature:
Fingerprint Technician Name (Printed/Typed):
Fingerprint Technician Agency/Company Name and Title:
