Fingerprint Information Form

Date Field

Full Name*

Social Security Number*

Date of Birth*

Date of Birth

E-mail*

Phone Number*

Address*

Gender

Male
Female

Place of Birth*

Hair Color*

Eye Color*

Height*

Weight*

Reason for Fingerprint

AHCA Employment/Enrollment or Medicaid
Fl. Dept of Children & Families
APD/Agency Person w/Disabilities
Fl. Dept of Education
Florida Dept of Health/Licensing
Florida Department of Revenue
Other

By checking this box and signing below you are validating that the information you inputed is accurate. You also acknowledge that If there is any information that is incorrect and ProxiCare submits with the incorrect information that you entered, the prints will be rejected and ProxiCare will have to resubmit. As a result a new fee will be charged. In addition you authorize ProxiCare to use the information provided to submit and process your prints.

ORI# (FOR OFFICE STAFF ONLY)

TRACKING# (FOR OFFICE STAFF ONLY)

AMOUNT PAID (FOR OFFICE STAFF ONLY)

File Upload - Fingerprint Form (FOR OFFICE STAFF ONLY)