Applicant Request Form for Background Screening

Application Request for Background Screenings

Care Provider Background Screening Clearinghouse Background Screening Request Form
Care Provider Background Screening CleariYou have applied for a position with a health care and/or service provider regulated by a specified agency in the Care Provider Background Screening Clearinghouse (Clearinghouse) that requires a fingerprint-based background check. As a health care and/or service provider regulated by a specified agency in the Clearinghouse we may conduct a search for an existing background screening result or submit a new background screening request through the Clearinghouse results website on your behalf.
In order to complete the search and/or background screening request we must collect the following information. This information is required by the Clearinghouse, the Florida Department of Law Enforcement, and the Federal Bureau of Investigation.
Applicant Information
Full Name*
First Middle Last
SSN*
Date of Birth*
MM slash DD slash YYYY
Place of Birth*
Demographics
Sex*
Race*
Hair Color*
Eye Color*
Height*
Weight*
Contact Information
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Prior States*
Email*
Phone*