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RI-030 03/2011 MICHIGAN STATE POLICE LIVESCAN FINGERPRINT REQUEST Return completed form after fingerprint capture to Employer or state licensing authority I. CJIS Information Type or clearly print answers to all fields. 1. Date Printed 2. Picture ID Type Presented 3. TCN Number 4. Live Scan Operator 5. Requesting Agency ID 6. Agency Name 1963K Boyne City Public Schools tpatrick boyne. k12. mi. us II. Applicant Information Type or clearly print answers to all fields. 1a* First Name 1b. Middle Initial 1c* Last Name 2. Date of Birth 3. Race 4. Sex 7. State 8. ZIP Code 5. Address 6. City Fingerprint Reason Code SE School Employment I understand the personal information and fingerprints submitted by live scan are used to search against criminal identification records from both the Michigan State Police MSP and Federal Bureau of Investigation FBI. I hereby authorize the release of any records to the person or agency listed above. I further understand MSP and the FBI may also retain the submitted information and fingerprints as permitted by the Federal Privacy Act of 1974 5 USC 552a b for routine uses beyond the principal purpose listed above. Routine uses include but are not limited to disclosures to governmental authorities responsible for civil or criminal law enforcement counterintelligence national security or public safety. Signature Date 28 CFR 16. 34- Procedure to obtain change correction or updating of identification records. If after reviewing his/her identification record the subject thereof believes that it is incorrect or incomplete in any respect and wishes changes corrections or updating of the alleged deficiency he/she should make application directly to the agency which contributed the questioned information* The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI Criminal Justice Information Services CJIS Division ATTN SCU Mod. D2 1000 Custer Hollow Road Clarksburg WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency. DISCLAIMER ALL FINGERPRINTS PROCESSED WITH INCORRECT FINGERPRINT CODES ARE THE RESPONSIBILITY OF THE REQUESTING AGENCY. MSP WILL CHARGE FOR SECOND REQUESTS DUE TO INCORRECT FINGERPRINT CODES* AUTHORITY MCL 28. 214 MCL 28. 273 MCL 28. 162 COMPLIANCE Voluntary however failure to complete this Agreement will result in denial of request. CJIS Information Type or clearly print answers to all fields. 1. Date Printed 2. Picture ID Type Presented 3. TCN Number 4. Live Scan Operator 5. Requesting Agency ID 6. Agency Name 1963K Boyne City Public Schools tpatrick boyne. TCN Number 4. Live Scan Operator 5. Requesting Agency ID 6. Agency Name 1963K Boyne City Public Schools tpatrick boyne. k12. mi. us II. Applicant Information Type or clearly print answers to all fields. 1a* First Name 1b.

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