Florida CardScan Client Intake Form

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Before You Begin

This form will request the following:

ORI Number (specific to your Florida application)

Government-issued photo ID (upload an image or mail with cards)

For Healthcare Licensing/Employment Only:

SSN or ITIN

Recent ID photo (clear background, no hats or glasses, taken within the last 30 days — phone, camera, or passport photo accepted)

👉 You may upload your ID and photo directly to this form or mail them along with your fingerprint cards.

Having these ready will help you complete the process smoothly.
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Full Name* This field is required.
First Name
Last Name
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Middle Name
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Aliases (if any)
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Full Maiden Name (if any)
First Name
Last Name
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Additional Aliases, Maiden Names, or Other Names Used If you've ever used other names (e.g., maiden names, previous married names, or aliases), please list your full name as used at the time (First, Middle, Last).
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Date of Birth* This field is required.
Date
Month
Day
Year
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Gender* This field is required.
F- FEMALE
M- MALE
X- UNKNOWN
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Race/Ethnicity* This field is required.
Please Select
Please Select
A- Asian
B- Black
I- American Indian
U- Of Indeterminable Race
W- Caucasian
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Height (in feet and inches)* This field is required.
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Weight (in pounds)* This field is required.
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Hair Color* This field is required.
Please Select
Please Select
Black
Brown
Blonde
Red
Gray
Other
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Eye Color* This field is required.
Please Select
Please Select
Black
Brown
Blue
Green
Hazel
Gray
Other
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Were you born in the United States, Canada, or Mexico? (Yes/No)* This field is required.This helps us determine what specific location details to collect for your submission.
Please Select
Please Select
Yes
No
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State of Birth* This field is required.If you were born in the U.S., Canada, or Mexico, please enter the state or province.
Which state were you born in
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Country of Birth* This field is required.Enter the name of the country you were born in — even if you were born in the U.S., Canada, or Mexico.
Name of the country you were born in
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Country of Citizenship* This field is required.Enter the country you are currently a legal citizen of. (This may be different from your country of birth.)
Name of country you are currently a citizen of
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ORI#* This field is required.This number is usually provided in the instructions or email that told you to get fingerprinted. If you're not sure, check with the agency or organization that sent you for fingerprinting. An ORI# is required to submit your request. Add additional ORI numbers here, if applicable.
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Screening ID (if any)Usually only applies to healthcare workers. If you received a Screening ID after registering in the CHAI system, enter it here. Otherwise, you can leave this blank.
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Are you getting fingerprinted for a job or license in healthcare? (Y/N)* This field is required.This helps us determine if a photo and SSN/ITIN is required with your submission.
Please Select
Please Select
Yes
No
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What is your professional title or role? * This field is required.Examples: Registered Nurse, Realtor, Pharmacist, Teacher, LPN, Medical Doctor, General Contractor, etc.
Or, just explain reason you need fingerprinting background check done
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Do you have a valid U.S. Social Security Number or ITIN? (Required for Florida Department of Health submissions)To process your Florida Card Scanning request as a healthcare worker, the Florida Department of Health requires you to provide either a valid U.S. Social Security Number (SSN) or an Individual Taxpayer Identification Number (ITIN). If you do not have a Social Security Number, you may apply for an ITIN through the IRS: 👉 https://www.irs.gov/individuals/how-to-apply-for-an-itin Please do not proceed unless you have one of these numbers.
I do have a valid U.S. SSN or ITIN number
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Full SSN or ITIN
Full Social Security or Tax ID number for submission
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Additional SSN or ITIN If applicable, list up to three additional Social Security Numbers (SSNs) or Individual Taxpayer Identification Numbers (ITINs) that may be associated with your records. ➤ Leave blank if not applicable.
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Upload Your Photo: Please upload a clear chest-up photo taken within the last 30 days, with space above your head and a solid light or dark background. 🚫 No glasses or headwear allowed.📸 You can take the photo yourself using a phone or camera — just make sure it's clear and well-lit. (It helps to have someone else take it.) OR you can get a passport-style photo taken and mail it in with your fingerprint card.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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Upload a Copy of Your C (Front)Please upload a clear image of the front of your valid government-issued ID. 🪪 A driver’s license is preferred. OR you may mail a paper copy of your ID along with your fingerprint card.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Driver’s license prefered
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Upload a Copy of Your Government-Issued ID (Back)Please upload a clear image of the back of the same ID. 🪪 A driver’s license is preferred. OR you may mail a paper copy of your ID along with your fingerprint card.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Driver’s license prefered
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Upload Your LiveScan Request Form (Optional)Some healthcare workers receive an email invitation to register through the CHAI system before getting fingerprinted. Once registration is complete, you’ll be issued a LiveScan Request Form that includes your ORI Number and Screening ID. 📎 If you have that form, feel free to upload it here to help us process your submission faster.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Example of an FD-258 fingerprint cardCards must be completed using black ink. Avoid smudging. Poor quality prints may be rejected.
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Mail in Your Fingerprints Please mail two completed FD-258 fingerprint cards with your fingerprints taken by a local police department or independent fingerprinting service* This field is required.📦 Be sure to use a tracked mailing service for your protection. 📬 Send to: Macon LiveScan Services 1305 Hardeman Ave, Suite 200 Macon, GA 31201
I will mail my fingerprint cards
I have already mailed my fingerprint cards.
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I confirm that I have reviewed all information for accuracy, spelling, and completeness. I understand that if my submission contains errors requiring resubmission, I will be responsible for additional fees for reprocessing.* This field is required.
I agree
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Once payment is submitted, all sales are final and non-refundable.* This field is required.There are no refunds for failure to submit required documentation or for delays caused by missing or incomplete materials. You must mail your completed fingerprint cards to: 📬 Macon LiveScan Services 1305 Hardeman Ave, Suite 200 Macon, GA 31201 A clear copy of your government-issued photo ID and a recent passport-style photo must be either uploaded through this form or mailed with your fingerprint cards. ⚠️ Failure to follow these instructions may result in processing delays or inability to complete your submission. Refunds will not be issued under these circumstances.
I agree
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Signature* This field is required.
Powered by Jotform SignClear
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Florida Card Scan PaymentPay in full using any method below Or choose Afterpay to split your total into 4 easy payments. 💳 Pay just $62.25 today — Afterpay covers the rest. You’ll pay Afterpay over time in 3 more interest-free installments.
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ORDER SUMMARY
Total costUSD
Florida CardScan Florida Live Scan by fingerprint card
$249.00Edit
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Additional ORI NumbersThis option is for clients who need their fingerprints submitted to more than one Florida agency.The first ORI number is already included in your Live Scan or Card Scan service.Select this add-on if you have additional ORI numbers for other licenses or agencies (for example, both a nursing license and a real estate license).Each additional ORI number will be processed using the same set of fingerprints — no need to be printed again.
$125.00Edit
Back
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Total cost $0.00
Payment Methods
Credit Card
First Name
Last Name
Cash App
After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
ACH Bank Transfer
Account Holder Name
Afterpay
After submitting the form, you will be redirected to the Afterpay to complete the payment process.
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