STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES CRIMINAL JUSTICE INFORMATION SYSTEMS - CENTRAL REPOSITORY
LIVESCAN PRE-REGISTRATION APPLICATION
APPLICANT INFORMATION (PLEASE ENSURE EVERYTHING IS ACCURATE BEFORE SUBMITTING)
Course Date
*
-
Month
-
Day
Year
Enter the date of your class
Name
*
First Name
Middle Name (if applicable)
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
SSN (prevents misidentification)
Gender
*
Male
Female
Height (feet)
*
Height (inches)
*
Weight (lbs only)
*
Eye Color
*
Please Select
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Multicolor
Pink
Unknown
Hair Color
*
Please Select
Bald
Black
Blond/Strawberry
Blue
Brown
Gray/Partially Gray
Green
Orange
Pink
Purple
Red/Auburn
Sandy
White
Unknown
Race
*
Black
White
Native American
Asian/Pacific Islander
Other
Place of Birth (State or Foreign Country)
*
Citizenship
*
Current address (Include Apt # if applicable)
*
City
*
State
*
ZIP Code
*
Phone Number
*
Format: (000) 000-0000.
Driver's License #
*
Driver's License Expiration Date
*
-
Month
-
Day
Year
Date
Occupation
*
Request Type (Choose One)
*
Wear & Carry / HQL
Other
Agency Authorization #
*
Please Select
9400082484 (Wear & Carry)
1300004845 (HQL)
Other / Unknown
ORI #
*
Please Select
MDMSP6000 (Wear & Carry)
MD920511Z (HQL)
Other / Unknown
Reason fingerprinted? (Enter Handgun Qualification License or Wear & Carry // Enter "Other" if it is for something else)
*
All information entered above is accurate to the best of my knowledge.
*
Submit
Should be Empty: