DES-025 (Rev. 11/2012) By Authority of 2006 PA 384
Michigan Department of State
Licensing Unit
Lansing, MI 48918
Instructions for Applicant:
Live Scan Fingerprint Request
1.Complete APPLICANT INFORMATION below.
2.Schedule an appointment to be fingerprinted:
a.Visit www.michigan.gov/msp
b.In the Search box, type “Private Livescan Vendors,” and click on Go.
c.Select the MSP – Private Live Scan Vendors link for list of vendors.
3.Attend appointment, pay fee, and keep the receipt.
4.Bring picture ID and this completed form to the appointment.
Criminal history report will be forwarded to the Department of State by the Michigan State Police.
APPLICANT INFORMATION
Applicant Name: Last |
|
|
|
|
|
|
|
First |
|
|
|
|
Middle |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Date of Birth |
|
|
|
|
|
|
Race |
|
|
|
|
Gender |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Street Address |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
State |
|
Zip |
|
Phone |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Number ( |
) |
Check |
|
|
|
____ |
|
Owner, designated representative/coordinator, authorized official, etc. |
|
|
|
|
|
|
|
One: |
|
|
|
|
____ |
|
Instructor and/or Examiner |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Type of Picture |
|
|
|
|
Fingerprinted: ________________________________ |
ID Presented: ____________________________________________ |
|
|
|
|
|
|
|
|
REQUESTING AGENCY INFORMATION |
|
|
Agency ID: |
3720E |
|
|
|
|
|
|
|
Agency Name: |
Bureau of Driver and Vehicle Programs |
|
|
|
|
|
|
|
|
(RQID) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LDE – Dept of State, Driver Education Certification (MCL 256.649) |
|
Reason Fingerprinted: |
|
|
_____ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
_____ |
|
TPT – Third Party Tester (MCL 257.309) |
|
If you are both a driver education instructor and driving skills test examiner, check the LDE – Dept of State, Driver Education Certification.
Disclaimer: Any and all fingerprints processed with incorrect fingerprint codes/reasons, etc., are the applicant’s responsibility. Michigan State Police will charge for second requests due to an incorrect fingerprint reason.