APPLICANT INFORMATION

11500 Crossroads Circle Suite J - Middle River, MD 21220 410-335-5100 www.freestategunrange.com
STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES CRIMINAL JUSTICE INFORMATION SYSTEMS - CENTRAL REPOSITORY
LIVESCAN PRE-REGISTRATION APPLICATION
APPLICANT INFORMATION (PLEASE TYPE OR PRINT CLEARLY)
Date of Course

MonthDayYear
Date
Full Name*
Date of birth*

MonthDayYear
Date
SSN
Gender*

MaleFemale
Height (Feet)*
Height (Inches)*
Weight*
Eye Color*
Hair Color*
Race*

BlackWhiteAsian/Pacific IslanderNative AmericanOther/Unknown
State of Birth*
Country of Citizenship*
Current address*
City*
State*
ZIP Code*
Daytime Phone*
Evening Phone
Driver's License #*
Dr. Lic. Expiration Date*

MonthDayYear
Date
Occupation
AGENCY INFORMATION (Select ORI and Authorization)
Agency Authorization #:*
If not one of the above choice, leave blank
ORI #:*
If not one of the above, leave blank
Reason fingerprinted?
Position Applied for
I HAVE REVIEWED ALL THE DATA ENTERED INTO THE COMPUTER BY THE FINGERPRINT TECHNICIAN AND AGREE TO ITS
APPLICANT'S SIGNATURE*

Clear
Should be Empty:

APPLICANT INFORMATION (PLEASE TYPE OR PRINT CLEARLY)