Applicant Fingerprinting Form

Name:______Last First Middle Address:______

City:______State:______Zip:______

Daytime Contact # ______Social Security #:______-_____-______

Date of Birth:_____/_____/_____ Birthplace:______Month Day Year State

Citizenship:______Height:______Weight:______

Original TCN (if this is a reprint) ______

CIRCLE CODES THAT APPLY

SEX HAIR COLOR EYE COLOR Male ...... M Female...... F Bald ...... BAL Black ...... BLK Black ...... BLK Blue ...... BLU RACE Brown ...... BRO Brown ...... BRO Asian or Pacific Islander . . A Gray/Part Gray . . . GRY Gray ...... GRY Black ...... B Red/Auburn ...... RED Green ...... GRN American Indian or Sandy ...... SDY Hazel ...... HAZ Alaskan ...... I White ...... WHI Maroon ...... MAR Unknown ...... U Multicolored . . . . . MUL White ...... W Pink ...... PNK

Go to www.L1Enrollment.com or call 1-877-472-6917 to schedule fingerprinting appointments. Use requesting agency information below to ensure correct processing and fees.

Please bring your Drivers License (or other State or Federal issued Photo ID) to your fingerprint appointment

Requesting Agency Information (This information must be provided by your REQUESTING AGENCY.)

Agency Name: Professional Licensing Agency Applicant Category: Real Estate Appraiser

A criminal history background check is required for a real estate appraiser license in Indiana pursuant to Indiana law. The information submitted with this application and the criminal history report itself are confidential. The criminal history report is used solely by the Indiana Professional Licensing Agency as a condition precedent for licensure. Neither the application nor the criminal history report is accessible through or by a public records request except as otherwise provided by law.”