*Florida Hard Card Scan Client Intake Form

Full Name*

First NameLast Name

Middle Name

If you have used other legal names (e.g., maiden name), list them here one per line. Formatted as: First Name, Middle Name, Last Name.

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Gender*

F- FEMALEM- MALEX- UNKNOWN

Height (in feet and inches)*

Race/Ethnicity*

Weight (in pounds)*

Hair Color*

Eye Color*

Were you born in the United States, Canada, or Mexico? (Yes/No)*

State of Birth*

Which state were you born in?

Country of Birth*

Name of the country you were born in.

Country of Citizenship*

Name of country you are currently a citizen of.

Does your fingerprinting background check go through Florida’s Department of Health / AHCA Clearinghouse system?*

If you’re in healthcare, education, or childcare, the answer is likely yes. This helps us determine if a photo and SSN/ ITIN is required with your submissions.

ORI Number: (Required for submission — provided by your requesting agency)*

Add additional ORI numbers, if applicable.

Screening ID (if applicable)

Originating Agency Case Number (If Applicable)

Most Applicants can leave this blank.

Additional Numbers Requested by Your Agency (If Applicable)

Most applicants can skip this section. Only complete this if your requesting agency case number, reference number specifically gave you an additional number to include (such as Agency Case Number).

Additional Agency Number (If Provided)

Enter the number exactly as provided by your requesting agency. Most applicants can leave this blank.

What is your professional title or role? *

Or, just explain reason you need fingerprinting background check done

Do you have a valid U.S. Social Security Number or ITIN? (Required for Florida Department of Health submissions)*

I do have a valid U.S. SSN or ITIN numberNo I don't have a valid U.S. SSN or ITIN number

🚫 IMPORTANT – Submission Cannot Continue

If your fingerprints are being submitted for the Florida Department of Health (DOH), AHCA, or the Clearinghouse, a valid U.S. Social Security Number (SSN) or IRS-issued ITIN is required for submission.

If you do not have an SSN or ITIN, you may be able to apply for an ITIN through the IRS, even if you're not a US citizen.

Learn more: How to apply for an ITIN

LINK

Because you indicated that you do not currently have a valid SSN or ITIN, we are unable to submit your fingerprints for these Florida healthcare agencies at this time.

Please do not proceed with payment. Any submissions without a valid SSN or ITIN cannot be processed or refunded.

Full SSN or ITIN*

Full Social Security or Tax ID number for submission

Full SSN or ITIN (Optional)

Additional SSNs or ITINs

Upload Your Photo: Please upload a clear chest-up photo taken within the last 30 days, with space above your head and a solid light or dark background. 🚫 No glasses, or headwear allowed.

Upload a Copy of Your Government-Issued ID (Front)

Driver’s license prefered

Upload a Copy of Your Government-Issued ID (Back)

Driver’s license prefered

Upload Your LiveScan Request Form (Optional)

📦 Be sure to use a tracked mailing service for your protection.
📬 Send to:

Macon LiveScan Services
c/o Miranda Holland
1305 Hardeman Ave, Suite 200
Macon, GA 31201

📬 Please mail two completed FD-258 fingerprint cards that were taken by a local police department or independent fingerprinting service. Be sure to use a tracked mailing service for your protection.*

I plan to mail my fingerprint cardsI already mailed my fingerprint cards.

Note any special instructions or other helpful info you would like us to know?(Optional)

I confirm that I have reviewed all information for accuracy, spelling, and completeness. I understand that if my submission contains errors requiring resubmission, I will be responsible for additional fees for reprocessing.*

I agree

Once payment is submitted, all sales are final and non-refundable.*

I agree

Signature*

My Products*

Florida Hard Card Scan Florida Live Scan by fingerprint card

$249.00 Quantity

Additional ORI NumbersThis option is for clients who need their fingerprints submitted to more than one Florida agency. The first ORI number is already included in your Live Scan or Card Scan service. Select this add-on if you have additional ORI numbers for other licenses or agencies (for example, both a nursing license and a real estate license). Each additional ORI number will be processed using the same set of fingerprints — no need to be printed again.

$125.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Florida Card Scanning Client Intake Form

Professional Title & Document Uploads

Cancellation & Refund Policy

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