"Fingerprint Request Form" - Nevada

Fingerprint Request Form is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Fingerprint Request Form" - Nevada

Download PDF

Fill PDF online

Rate (4.5 / 5) 29 votes
Page background image
EMERGENCY MEDICAL SYSTEMS
4150 Technology Way, Ste 101
Carson City, Nevada 89706
Telephone (775) 687-7590 • Fax (775) 687-7595
http://dpbh.nv.gov/Reg/EMS/EMS-home/
FINGERPRINT REQUEST FORM
Please provide this form to the fingerprint technician at the time the fingerprints are taken to ensure that all fields contain
the required information needed for processing. Applicants without a Fingerprint Request Form or with an incomplete
Fingerprint Request Form may be denied fingerprinting until all applicable information is received.
Fingerprint technician, please ensure that you see a government issued photo ID for identity verification purposes prior to
fingerprinting and return form to the applicant when completed.
Applicant Information:
Name (Last, First, MI): ____________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________
City, State, Zip: _____________________________________________________________________________________________________________________________
Date of Birth: ___________________________________________________ Place of Birth: _________________________________________________________
SSN: ______________________________________________________________ Citizenship: ____________________________________________________________
Sex: __________
Race: __________ Height: __________
Weight: __________
Eyes: __________ Hair: __________
Authorized Entity Information:
Account No. (MNU): 880485
ORI: NV0131700
Reason Fingerprinted: NRS450B.800
Fingerprint Site Information:
(circle yes or no)
(circle one)
Did Applicant Pay $40.75 Processing Fee? Yes | No
Type of Fingerprint Submission: Fingerprint Cards | LiveScan
Signature and Date of Official Taking Prints: _________________________________________________________________________________________
TCN No. (used for tracking purposes): _________________________________________________________________________________________________
EMERGENCY MEDICAL SYSTEMS
4150 Technology Way, Ste 101
Carson City, Nevada 89706
Telephone (775) 687-7590 • Fax (775) 687-7595
http://dpbh.nv.gov/Reg/EMS/EMS-home/
FINGERPRINT REQUEST FORM
Please provide this form to the fingerprint technician at the time the fingerprints are taken to ensure that all fields contain
the required information needed for processing. Applicants without a Fingerprint Request Form or with an incomplete
Fingerprint Request Form may be denied fingerprinting until all applicable information is received.
Fingerprint technician, please ensure that you see a government issued photo ID for identity verification purposes prior to
fingerprinting and return form to the applicant when completed.
Applicant Information:
Name (Last, First, MI): ____________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________
City, State, Zip: _____________________________________________________________________________________________________________________________
Date of Birth: ___________________________________________________ Place of Birth: _________________________________________________________
SSN: ______________________________________________________________ Citizenship: ____________________________________________________________
Sex: __________
Race: __________ Height: __________
Weight: __________
Eyes: __________ Hair: __________
Authorized Entity Information:
Account No. (MNU): 880485
ORI: NV0131700
Reason Fingerprinted: NRS450B.800
Fingerprint Site Information:
(circle yes or no)
(circle one)
Did Applicant Pay $40.75 Processing Fee? Yes | No
Type of Fingerprint Submission: Fingerprint Cards | LiveScan
Signature and Date of Official Taking Prints: _________________________________________________________________________________________
TCN No. (used for tracking purposes): _________________________________________________________________________________________________