Maryland Livescan

Livescan Fingerprinting express Registration
CHILD CARE LICENSING
State of Maryland

Instructions: Complete all required sections of this form. Review all information entered is correct. Click the "Register Now" button and you will prompted for payment of the required fee. Express registration is nonrefundable or transferable. You must appear within 30 day's of submitting your registration to be fingerprinted with a valid photo ID and copy of your paid receipt.

*CJIS Authorization Number:

Child Care Admin. Number:

*Last Name:

*First Name:

Middle Name:

*Date of Birth:

yyyy-mm-dd

*Sex:

*Race:

*Height:

5'2"=502, 5'8"=508

*Weight:

Lbs.

*Eye Color:

*Hair Color:

*Place of Birth:

*Country of Citizenship:

*Home Address:

Complete address including City, State, Zip Code

*Phone Number:

Driver's License Information:

Issuing State & Number

*Disclosure Statement: (Selection Required)
I hereby declare and affirm under the penalties of Perjury, that I
	HAVE NOT been convicted, received a probation before judgment, received a non criminally responsible disposition, and AM NOT the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.
	HAVE NOT been convicted, received a probation before judgment, received a non criminally responsible disposition, and AM the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.
	HAVE been convicted, received a probation before judgment, received a non criminally responsible disposition, and AM NOT the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.
	HAVE been convicted, received a probation before judgment, received a non criminally responsible disposition, and AM the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.