Florida Card Scanning Client Intake Form
Please provide accurate and complete information for your Florida card scan processing. Ensure all uploaded images are clear.
Does your fingerprinting background check go through Florida’s Department of Health / AHCA Clearinghouse system?
*
Please Select
Yes
No
If you’re in healthcare, education, or childcare, the answer is likely yes. This helps us determine if a photo and SSN/ ITIN is required with your submissions
Full Name
*
First Name
Last Name
Middle Name
Aliases (if any)
Full Maiden Name (if any)
First Name
Last Name
Additional Aliases, Maiden Names, or Other Names Used
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
F- FEMALE
M- MALE
X- UNKNOWN
Height (in feet and inches)
*
Race/Ethnicity
*
Please Select
A- Asian
B- Black
I- American Indian
U- Of Indeterminable Race
W- Caucasian
Weight (in pounds)
*
Hair Color
*
Please Select
Black
Brown
Blonde
Red
Gray
Other
Eye Color
*
Please Select
Black
Brown
Blue
Green
Hazel
Gray
Other
Were you born in the United States, Canada, or Mexico? (Yes/No)
*
Please Select
Yes
No
State of Birth
*
Which state were you born in
Country of Birth
*
Name of the country you were born in
Country of Citizenship
*
Name of country you are currently a citizen of
ORI#
*
Screening ID (if any)
Professional Title & Document Uploads
Let us know what professional license or certification you're pursuing, and upload the required documents.
What is your professional title or role?
*
Or, just explain reason you need fingerprinting background check done
Do you have a valid U.S. Social Security Number or ITIN? (Required for Florida Department of Health submissions)
*
I do have a valid U.S. SSN or ITIN number
Full SSN or ITIN
*
Full Social Security or Tax ID number for submission
Full SSN or ITIN (Optional)
Additional SSN or ITIN
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, hats, or headwear allowed.
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload a Copy of Your Government-Issued ID (Front)
Upload a File
Drag and drop files here
Choose a file
Driver’s license prefered
Cancel
of
Upload a Copy of Your Government-Issued ID (Back)
Upload a File
Drag and drop files here
Choose a file
Driver’s license prefered
Cancel
of
Upload Your LiveScan Request Form (Optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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
*
I will mail my fingerprint cards
I have already mailed my fingerprint cards.
Cancellation & Refund Policy
(Please Read Carefully)
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.
*
I agree
Once payment is submitted, all sales are final and non-refundable.
*
I agree
Signature
*
My Products
*
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Florida CardScan
Florida Live Scan by fingerprint card
$
249.00
Quantity
1
Additional ORI Numbers
This 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.
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
Submit
Submit
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