IC Biometric – Client Intake, Consent & Payment
Please complete this form to select your requested service(s), provide required contact information, and review and consent to applicable policies.
Please select the service(s) requested
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Fingerprinting
Drug Testing
Notary
Passport Photos
Is this a walk-in appointment
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Yes
No
Full Name
*
First Name
Last Name
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment
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Fingerprint section
Reason for Fingerprinting
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Employment
Licensing / Certification
Background Check
Volunteer / Church
Adoption / Foster Care
Personal Record / Self-Request
Recipient/Agency for Fingerprint Results (if applicable)
Employer/Organization Name (if applicable)
Is This a Mobile Fingerprint Appointment?
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Yes
No
mobile cal
Required Consent
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I authorize IC Biometric to capture and transmit my fingerprints for the purpose stated above. I understand fingerprint processing times are determined by the receiving agency, and IC Biometric does not control processing outcomes or timelines.
Drug Test & Rapid Testing Section
Drug & Rapid Testing
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5-Panel Instant (CLIA-Waived)
10-Panel Instant (CLIA-Waived)
5-Panel Lab
10-Panel Lab
Hair 5-Panel
Hair 10-Panel
Flu Test
Strep Test
Pregnancy Test (Urine)
Rapid Urinalysis
Urinalysis Dip
Glucose Test
Blood Pressure
Eye/Vision Screening
Hearing Test
Respirator Fit Testing
Required Acknowledgment
*
I understand that test results are confidential and may only be released to the requesting employer, agency, or authorized party as permitted by applicable laws and guidelines.
I understand this is a CLIA-waived screening test and results are not a substitute for medical diagnosis.
I consent to the collection of biological specimens for drug and/or alcohol testing in accordance with applicable guidelines. I understand that refusal or tampering may invalidate results and may be reported to the requesting employer or agency.
Confirm Age
*
Is This Self-pay?
*
Yes
No
Employer Name (If applicable)
Reason for Test
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Please Select
• Pre-Employment
• Random (Employer Program)
• Reasonable Suspicion
• Post-Accident / Incident
• Return-to-Duty
• Follow-Up Testing
• Court-Ordered / Legal
• Personal / Self-Requested
• School / Program Requirement
Notary Section
Document Type
*
Please Select
Power of Attorney
Affidavit
Deed / Property Document
Bill of Sale
Consent / Authorization Form
Financial Document
Other
You've selected other, please specify
*
How many pages need to be notarized?
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1
More than 1
Number
*
number cal
Signee
*
Myself
Signing on behalf of another person or entity
Required Acknowledgments
*
I affirm that I am signing willingly, understand the document presented, and acknowledge the notary does not provide legal advice or determine document validity.
I understand documents must be unsigned prior to notarization and all signers must appear in person with valid identification.
Passport Section
What's the number of individuals Needing a Passport Photo
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Passport cal
Passport cal 2
passport cal 3
U.S. Passport Photo Requirements - Please confirm each item below.
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I am not wearing glasses (unless medically or religiously required)
My face is fully visible with a neutral expression
I am not wearing hats or head coverings (unless religious)
My photo will be taken against a plain, light background
I understand photos must meet U.S. government requirements
**All requirements above must be acknowledged before proceeding with passport photo services.**
Required Acknowledgment
*
I understand passport photo acceptance is determined solely by the U.S. Department of State. Fees are non-refundable once photos are taken. Retakes are offered only for photographic errors, not for appearance or preference.
Acknowledge, sign, payment
Required Acknowledgment
*
I consent to the collection and processing of my personal information for the purpose of providing the selected services. I understand that a valid government-issued ID may be required and that service fees are non-refundable once services have been rendered.
Required Acknowledgment
*
I understand that appointments are not confirmed until payment is completed. By submitting this form and signing below, I acknowledge the IC Biometric Fingerprint Service Cancellation & Refund Policy and authorize IC Biometric Fingerprint Services to provide the selected services and process payment.
Electronic Signature Authorization
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By signing below, you confirm that the information provided is accurate and that you authorize IC Biometric to perform the selected services.
E-Signature (Sign below to authorize services and payment)
*
Payment Amount
*
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