Phone: 773-685-5699
Fax: 773-685-5433
Out of State Fingerprinting Form
Last Name: _______________________First Name: ______________MI___
Address: _____________________________City:_____________________
State: _______ Zip Code: __________ Date of Birth: ____/_____/____
Sex: ______ Race: ______ Height: ______ Weight: ______Hair Color: ______
Eye Color: ______ Social Security #:_______-_____-_________
Place of Birth: (State or Country if outside USA):__________________
Please check purpose of fingerprinting below:
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Security (PERC)
Massage Therapy
Chiropractic Licensee
Chiropractic Licensee by Endorsement
Physician Licensee
Physician Licensee by Endorsement
Be sure to include the following in mailing envelope to Accurate Biometrics
Fingerprint Cards-Flat Envelope Preferred
Payment-Money order, company check or credit card payment form NO PERSONAL CHECKS
Out of State Fingerprinting Form
Identity Verification Certifying Statement
Please provide information below in the event we need to contact you regarding your submission and
for Accurate Biometrics to email a copy of your receipt.
Phone # (____) __________________
Email Address: _____________________________________________________
(Please print neatly in all capital letters)