THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4790 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
STATEWIDE APPLICANT FINGERPRINT IDENTIFICATION SERVICES (SAFIS)
State Agency SAFIS Results (SAFIS‐R) User Designation Form
As part of the Commonwealth of Massachusetts Statewide Applicant Fingerprint Identification Services (SAFIS)
program, the Massachusetts Department of Criminal Justice Information Services (DCJIS) will disseminate state
and national criminal history record check results to an authorized Commonwealth of Massachusetts State
Agency using the non‐criminal justice results system known as SAFIS Results (SAFIS‐R). Each designated user
with either direct access to the SAFIS‐R system or to SAFIS‐R data, must complete and submit a SAFIS‐R User
Designation Form. Designated users must be approved by the Agency Head or designee.
Please complete this section for your designated SAFIS‐R user.
User*: ADD CHANGE REMOVE (Select One)
User Full Name (First, MI, Last, Suffix)*:
User Agency Title*:
User Agency E‐mail Address*:
User Agency Name*:
User Agency Phone Number*:
User Agency Street Address*:
User Agency City, State, Zip*:
Are you an Information Technology Contractor?
YES NO
Do you require a SAFIS‐Results User Account? YES
NO
Please complete this section for the approving Agency Head or Designee.
Full Name*:
Title*:
Signature*:
Date*:
*Required Field.
Please scan and e‐mail the completed form to safis@state.ma.us with the email subject line:
SAFIS‐R User Designation Form‐<Insert Agency Name>
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