Form 6696 Authorization to Disclose Criminal History Records Information - Louisiana

Form 6696 or the "Authorization To Disclose Criminal History Records Information" is a form issued by the louisiana department of public safety.

Download a PDF version of the Form 6696 down below or find it on the louisiana department of public safety Forms website.

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SUBMIT TO:
Louisiana State Police
Bureau of Criminal Identification and Information
P.O. Box 66614 (Mail Slip A-6)
Baton Rouge, LA 70896
THE FEE FOR PROCESSING A STATE BACKGROUND CHECK IS $26. FOR FBI PROCESSING, WHERE AUTHORIZED OR REQUIRED, THERE IS
AN ADDITIONAL $14.75 FEE.
Acceptable forms of payment include: Cashier Check, Business Check with pre-printed business name or Money Order
Credit Card payments are accepted when paying in person at Louisiana State Police Headquarters
**FORMS MUST BE FILLED OUT IN INK AND BE REVIEWED BY SUBMITTING AGENCY/INDIVIDUAL FOR ACCURACY**
****FINGERPRINTS ARE NECESSARY FOR A POSITIVE IDENTIFICATION****
_____________________________________________________________________________________________________________________________________________________________________________________
****PLEASE PRINT****
________________________________________ _____________________________________
AGENCY, FACILITY OR INDIVIDUAL
AGENCY, FACILITY AUTHORIZED REPRESENTATIVE OR INDIVIDUAL
________________________________________ _____________________________________
MAILING ADDRESS
SIGNATURE OF AUTHORIZED REPRESENTATIVE/INDIVIDUAL
_________________________________________ (_______)___________________________
CITY
STATE
ZIP CODE
AGENCY, FACILITY OR INDIVIDUAL PHONE NUMBER
AGENCY OR FACILITY E-MAIL ADDRESS
Request For: (pick one only)
□ ALCOHOL BEVERAGE OUTLET
□ LA STATE BOARD SOCIAL WORK EXAMINERS
□ BEHAVIOR ANALYST BOARD
□ LICENSED PROFESSIONAL COUNSELORS
□ BOARD OF EXAMINERS OF PSYCHOLOGIST
□ MEDICAL EXAMINERS
□ BOARD OF NURSING HOME ADMINISTRATORS
□ OFFICE OF FINANCIAL INSTITUTIONS
□ CASA
□ OMVC – COMMERCIAL DRIVING EXAM ADMINISTER
□ COURT ORDER ADOPTION
□ OMVE – EMPLOYEE ISSUING COMMERCIAL DL
□ CRIMINAL JUSTICE EMPLOYEE
□ OMVI – CONTRACT PROCESS INQUIRY/TRANSACTION
□ DAYCARE
□ OMVT – AUTO TITLE COMPANY / PUBLIC TAG AGENT
□ DENTISTRY BOARD
□ PHARMACY BOARD
□ DEPT. OF INSURANCE – FRAUD DIVISION
□ POST SECONDARY EDUCATION
□ DEPT. OF REVENUE
□ PRACTICAL NURSING
(Public Registry of Motion Picture Investor Tax Credit)
□ DCFS ABUSE/NEGLECT INVESTIGATION
□ PRIVATE ADOPTION
□ DCFS CARETAKER
□ PRIVATE INVESTIGATORS
□ DCFS FOSTER/ADOPTIVE
□ PRIVATE SECURITY
□ DCFS PERSONNEL
□ PUBLIC HOUSING
□ DRUG AND DEVICE DISTRIBUTORS
□ REGISTERED NURSING
□ EMPLOYERS
□ RELIGIOUS ACTIVISTS
□ FIREFIGHTERS
□ SCHOOL
□ FIRE MARSHAL
□ SUPREME COURT COMMITTEE BAR ADMISSION
□ HEALTH CARE PROVIDER (Non Licensed)
□ TAXI DRIVERS
□ JUVENILE DETENTION CENTER
□ TESS WINDOW TINT
□ LA BOARD CHIROPRACTIC EXAMINERS
□ VOLUNTEER LOUISIANA COMMISSION
□ LA PHYSICAL THERAPY BOARD
□ WORKING WITH CHILDREN
APPLICANTS FULL NAME: _______________________________________________________________________________
****PRINT – USE INK****
LAST
FIRST
MIDDLE
{INCLUDE MAIDEN NAME & PREVIOUS MARRIED NAMES IF APPLICABLE}
APPLICANTS SIGNATURE: ______________________________________________________
APPLICANTS SOCIAL SECURITY # _ _ _ - _ _ - _ _ _ _
DATE OF BIRTH: _ _ / _ _ / _ _
ID or DRIVERS LICENSE #___________________& STATE
______ RACE ____
SEX ____
POSITION OR LICENSE APPLIED FOR ________________________________
AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION
By my signature above, I hereby authorize the Louisiana State Police to release all pertinent criminal record information maintained in their files, other
states files, or the FBI files (if applicable) which may confirm or deny my eligibility with the facility or agency named above. Pursuant to Title 28, C.F.R.,
Section 16.34, officials making the determination of suitability for licensing or employment shall provide the opportunity to complete, or challenge the
accuracy of, the information contained in the FBI identification record.
DPSSP 6696
Revised 02/16/2016
SUBMIT TO:
Louisiana State Police
Bureau of Criminal Identification and Information
P.O. Box 66614 (Mail Slip A-6)
Baton Rouge, LA 70896
THE FEE FOR PROCESSING A STATE BACKGROUND CHECK IS $26. FOR FBI PROCESSING, WHERE AUTHORIZED OR REQUIRED, THERE IS
AN ADDITIONAL $14.75 FEE.
Acceptable forms of payment include: Cashier Check, Business Check with pre-printed business name or Money Order
Credit Card payments are accepted when paying in person at Louisiana State Police Headquarters
**FORMS MUST BE FILLED OUT IN INK AND BE REVIEWED BY SUBMITTING AGENCY/INDIVIDUAL FOR ACCURACY**
****FINGERPRINTS ARE NECESSARY FOR A POSITIVE IDENTIFICATION****
_____________________________________________________________________________________________________________________________________________________________________________________
****PLEASE PRINT****
________________________________________ _____________________________________
AGENCY, FACILITY OR INDIVIDUAL
AGENCY, FACILITY AUTHORIZED REPRESENTATIVE OR INDIVIDUAL
________________________________________ _____________________________________
MAILING ADDRESS
SIGNATURE OF AUTHORIZED REPRESENTATIVE/INDIVIDUAL
_________________________________________ (_______)___________________________
CITY
STATE
ZIP CODE
AGENCY, FACILITY OR INDIVIDUAL PHONE NUMBER
AGENCY OR FACILITY E-MAIL ADDRESS
Request For: (pick one only)
□ ALCOHOL BEVERAGE OUTLET
□ LA STATE BOARD SOCIAL WORK EXAMINERS
□ BEHAVIOR ANALYST BOARD
□ LICENSED PROFESSIONAL COUNSELORS
□ BOARD OF EXAMINERS OF PSYCHOLOGIST
□ MEDICAL EXAMINERS
□ BOARD OF NURSING HOME ADMINISTRATORS
□ OFFICE OF FINANCIAL INSTITUTIONS
□ CASA
□ OMVC – COMMERCIAL DRIVING EXAM ADMINISTER
□ COURT ORDER ADOPTION
□ OMVE – EMPLOYEE ISSUING COMMERCIAL DL
□ CRIMINAL JUSTICE EMPLOYEE
□ OMVI – CONTRACT PROCESS INQUIRY/TRANSACTION
□ DAYCARE
□ OMVT – AUTO TITLE COMPANY / PUBLIC TAG AGENT
□ DENTISTRY BOARD
□ PHARMACY BOARD
□ DEPT. OF INSURANCE – FRAUD DIVISION
□ POST SECONDARY EDUCATION
□ DEPT. OF REVENUE
□ PRACTICAL NURSING
(Public Registry of Motion Picture Investor Tax Credit)
□ DCFS ABUSE/NEGLECT INVESTIGATION
□ PRIVATE ADOPTION
□ DCFS CARETAKER
□ PRIVATE INVESTIGATORS
□ DCFS FOSTER/ADOPTIVE
□ PRIVATE SECURITY
□ DCFS PERSONNEL
□ PUBLIC HOUSING
□ DRUG AND DEVICE DISTRIBUTORS
□ REGISTERED NURSING
□ EMPLOYERS
□ RELIGIOUS ACTIVISTS
□ FIREFIGHTERS
□ SCHOOL
□ FIRE MARSHAL
□ SUPREME COURT COMMITTEE BAR ADMISSION
□ HEALTH CARE PROVIDER (Non Licensed)
□ TAXI DRIVERS
□ JUVENILE DETENTION CENTER
□ TESS WINDOW TINT
□ LA BOARD CHIROPRACTIC EXAMINERS
□ VOLUNTEER LOUISIANA COMMISSION
□ LA PHYSICAL THERAPY BOARD
□ WORKING WITH CHILDREN
APPLICANTS FULL NAME: _______________________________________________________________________________
****PRINT – USE INK****
LAST
FIRST
MIDDLE
{INCLUDE MAIDEN NAME & PREVIOUS MARRIED NAMES IF APPLICABLE}
APPLICANTS SIGNATURE: ______________________________________________________
APPLICANTS SOCIAL SECURITY # _ _ _ - _ _ - _ _ _ _
DATE OF BIRTH: _ _ / _ _ / _ _
ID or DRIVERS LICENSE #___________________& STATE
______ RACE ____
SEX ____
POSITION OR LICENSE APPLIED FOR ________________________________
AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION
By my signature above, I hereby authorize the Louisiana State Police to release all pertinent criminal record information maintained in their files, other
states files, or the FBI files (if applicable) which may confirm or deny my eligibility with the facility or agency named above. Pursuant to Title 28, C.F.R.,
Section 16.34, officials making the determination of suitability for licensing or employment shall provide the opportunity to complete, or challenge the
accuracy of, the information contained in the FBI identification record.
DPSSP 6696
Revised 02/16/2016

Download Form 6696 Authorization to Disclose Criminal History Records Information - Louisiana

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