Arkansas State Board of Pharmacy CBC Form

Arkansas State Board of Pharmacy

Background checks and fingerprinting by Cantrell Live Scan.
APPLICANT INFORMATION

The following information is required by the FBI to initiate your background check. After completing this form, you will be re-directed to a payment option screen. The fee for the background check and fingerprinting is $65 and can be paid automatically after completing the state form. Our automated system charges $2.45. We will gladly accept checks or cash at the time of fingerprinting. After submitting this form online, please come to Cantrell Live Scan for fingerprinting. We are located at the corner of Cantrell & Mississippi at 7509 Cantrell Road, Suite 103A, Little Rock. We are on the ground floor in Tanglewood Business Center behind Edward's Food Giant. Office telephone: 501-570-6250 and a follow up email will be sent when this form is submitted.
Last Name*
First Name*
Middle Name
Maiden / All Other Names Used
Social Security #*
Date of Birth*

MonthDayYear
Date
State of Birth (Country of Birth if Outside U.S.)*
Sex*
Race*
Height*
Ex: 5ft 10in entered as 510
Weight*
Pounds
Eye Color*
Hair Color*
Please spell out your typical hair color
Driver's License # (Passport # if using as ID)*
State of Issuance (Driver's License) or Country if Passport: *
Address*

Mailing Address

Street Address Line 2

CityState

Zip Code
Zip Code*
Citizenship*
I understand that my personal information and fingerprints submitted by agency are used to search against criminal identification records from both Arkansas Crime Information Center (ACIC) and Federal Bureau of Investigation (FBI). I hereby authorize the release of any records to the person or agency listed above. I further understand ACIC and the FBI may also retain the submitted information and fingerprints as permitted by the Privacy Act of 1974, 5 USC § 552a, for routine uses beyond the principal purpose listed above.
Signature*

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Date*

MonthDayYear
Date
Email - This will only be used to contract you about this CBC form.
example@example.com
Phone Number - This will only be used to text or call you about this CBC form.
Please enter a valid phone number.
Should be Empty:

Arkansas State Board of Pharmacy

APPLICANT INFORMATION