National Louis University UCIA Thank you for choosing Accurate Biometrics for your fingerprinting needs. PLEASE PROVIDE THE FOLLOWING INFORMATION (PLEASE PRINT CLEARLY) Last name: First name:
Middle Initial:
Daytime Phone:
Date of Birth:
Sex:
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Male Female
(Circle one)
White
Hispanic Asian
American Indian/Alaskan
Other
R EQUESTOR I NFORMATION
Agency
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Street Address: City:
Zip
I, the undersigned, authorize Accurate Biometrics to capture and transmit my fingerprints and above-noted demographic data to the Illinois State Police. I understand that the Illinois State Police will return the results of the fingerprint search to the Requestor listed above. Signature Date
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F.P. Tech:
TCN:
Date Fingerprinted:
Accurate Biometrics 4849 N Milwaukee Suite 101 Chicago, IL 60630 Phone 773-685-5699 Fax 773-685-5433 Web site: www.accuratebiometrics.com
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