ARIZONA DEPARTMENT OF PUBLIC SAFETY

DPS 802-06857 Web Cover Page

This is a downloadable and fillable PDF version of the

Regular (non-IVP) Fingerprint Clearance Application Form.

Please be aware that you must follow all of the directions below to submit your electronic application.

➢ Complete the Application for a Fingerprint Clearance Card (“Application”). DPS will

accept either a handwritten or typed Application, however it must be complete.

➢ You will need to be fingerprinted. Contact your local law enforcement agency to see if

they provide fingerprinting services for the public, or contact a private fingerprinting service.

The facility you select must take your prints using the standard applicant fingerprint card

(Form FD-258).

➢ After you are fingerprinted, you will need to mail the following three items to the address

below:

✓ Completed Application

✓ Your fingerprints (on Form FD-258)

✓ Appropriate fee (follow instructions on the application)

MAIL TO: Applicant Clearance Card Team

PO Box 18390 - MD 3180

Phoenix, AZ 85005-83690

✓ Be sure to include your return address on the envelope.

➢ The above-listed items must be mailed in a 9” x 11” (or larger) envelope.

➢ Do NOT fold the fingerprint card! DPS will be unable to process your application if the

fingerprint card has been folded.

Note to Employers/Agencies/Fingerprinting Services:

When printing multiple applications for distribution to applicants, be sure to include all four

pages of the application.

DOUGLAS A. DUCEY

Governor

FRANK L MILSTEAD

Director

ARIZONA DEPARTMENT OF PUBLIC SAFETY

2102 WEST ENCANTO BLVD. P.O. BOX 6638 PHOENIX, ARIZONA 85005-6638 (602) 223-2000

“Courteous Vigilance”

DPS 802-06857 Revised 08-2018

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Applicant Clearance Card Team  (602) 223-2279

 Mailing address: P.O. Box 18390, Phoenix, AZ, 85005-8390

 Physical address: 2222 W. Encanto Blvd. Phoenix, AZ 85009

You can also apply on-line at https://www.azdps.gov/services/public/fingerprint

THIS IS A NON-IVP APPLICATION

If you need to apply for a Fingerprint Clearance Card for any of the following reasons you must submit an IVP

application, not this one:

• ADOE Certification (Teacher or other) – ARS § 15-534

• Charter School Instructor – ARS § 15-534

• Tutor or Teacher Prep Program – ARS § 15-183

• Public or Charter School Non-Certificated Personnel – ARS § 15-512

• Public or Charter School Contractor, Subcontractor or Vendor – ARS § 15-512

• School Bus Driver Certification – ARS § 28-3228

If this is the correct application, please continue

TO ENSURE YOU APPLICATION IS PROCESSED:

• Indicate the reason you are applying on the application (if unsure, check with your employer or agency)

• Submit the correct form of payment (see application for details). Pursuant to ARS § 41-1750(J), fees are non-refundable.

NOTE: When submitting multiple applications with one payment the limit is 30 applications per money order, business check, cashier’s check or

State of Arizona Companion Transaction Entry/Transfer.

• Complete all the items with a  on the application form

• Under “Applicant’s Complete Mailing Address” on the application, enter your mailing address where you personally receive

correspondence to ensure any correspondence regarding your application is sent directly to you.

NOTE: It is imperative to notify DPS should your mailing address change in the future to ensure receipt of all correspondence.

• Ensure your name and identifiers on the fingerprint card are EXACTLY the same as on the application

Failure to follow any of the above instructions will result in your application be returned to you unprocessed

Use the following FBI approved abbreviations and units of measure on the application form and fingerprint card:

Sex

F for Female or M for Male.

Race

I for American Indian or Alaskan Native, A for Asian or Pacific Islander, B for Black, W for Caucasian, or H for Hispanic.

Height

Please indicate your height in feet and inches (ex. 5' 7"). Do not use centimeters or meters.

Weight

Please indicate your weight in pounds. Do not use kilograms.

Eyes

BLK for Black, BLU for Blue, BRO for Brown, GRN for Green, GRY for Gray, or HAZ for Hazel.

Hair

BAL for Bald, BLK for Black, BLN for Blonde, BRO for Brown, GRY for Gray, ONG for Orange, PNK for Pink, PLE for Purple, RED for Red or Auburn, SDY for Sandy,

or WHI for White.

Place of

Birth

If born in the United States use a two-letter state code (ex. AZ for Arizona). If born outside the United States use a two-letter country code (ex. CD for Canada or MX

for Mexico). If you do not know the two-letter code of the state or country you were born in, write the full name of the state or country.

If you provide your email address on the application, you will receive notification via email regarding the status of your application.

WHERE CAN YOU GO TO GET FINGERPRINTED?

Contact your local law enforcement agency to see if they provide fingerprinting services for the public or contact a private fingerprinting service.

YOU WILL NEED TO SUBMIT ALL THE FOLLOWING ITEMS TOGETHERTO DPS:

1. Completed application form (white original) filled out correctly. (Keep the yellow copy for your records.)

2. Fingerprint card with your fingerprints and with the top portion filled out.

3. Appropriate fee in one of the acceptable forms of payment made payable to DPS.

Agency Abbreviation Legend for Application

DCS-Department of Child Services

DES-Department of Economic Security

DHS-Department of Health Services

BPT-Board of Physical Therapy

ADOT-AZ Department of Transportation

ADFI-AZ Department of Financial Institutions

ABDE-AZ Board of Dental Examiners

BTR-Board of Technical Registration

GO TO THE NEXT PAGE AND READ THE “NOTICE TO APPLICANT” INFORMATION BEFORE YOU FILL OUT THE APPLICATION

DPS 802-06857 Revised 08-2018

NOTICE TO APPLICANT

In accordance with ARS §41-1750(A)(2) and ARS §41-1758 et seq., the Arizona Department

of Public Safety (DPS) Applicant Clearance Card Team (ACCT) conducts fingerprint-based

criminal history record checks and exchanges the fingerprint data with the Federal Bureau of

Investigation. Further, as required by ARS §41-1750(G)(3), ARS §41-1758.03(F) and ARS

§41-1758.07(F), DPS releases an applicant’s criminal history record to the Arizona Board of

Fingerprinting upon the Arizona Board of Fingerprinting’s request for conducting good cause

exceptions.

Your fingerprints will be used to check the criminal history records of the state of Arizona and

of the FBI. DPS and the FBI may retain your fingerprints and associated information after the

completion of this application and, while retained, your fingerprints may continue to be

compared against other fingerprints, including latent fingerprints submitted to or retained by

DPS and the FBI.

If you have a criminal history record, the officials making the determination of your suitability

for the job, license, or other benefit must provide you the opportunity to complete or challenge

the accuracy of the information in the record. You should be afforded a reasonable amount

of time to correct or complete the record (or decline to do so) before officials deny you the

job, license, or other benefit based on information in the criminal history record.

The procedures for obtaining a change, correction, or updating of your FBI criminal history

record are set forth in Title 28, Code of Federal Regulations (CFR) Section 16.30 through

16.34. Information on how to review and challenge your FBI criminal history record can be

found at https://www.fbi.gov/ under Criminal History Summary Checks or by calling (304)

625-5590.

To obtain a copy of your Arizona criminal history record to review, update or correct, you can

contact the Arizona Department of Public Safety Criminal History Records Unit at (602) 223-

2222 or go to http://www.azdps.gov/services/public/records/criminal to obtain a Review

and Challenge packet.

KEEP THIS PAGE FOR YOUR RECORDS / DO NOT RETURN TO DPS

By signing the fingerprint clearance card application, you are acknowledging that

you have read this “Notice to Applicant”.

DOUGLAS A. DUCEY

Governor

FRANK L MILSTEAD

Director

ARIZONA DEPARTMENT OF PUBLIC SAFETY

2102 WEST ENCANTO BLVD. P.O. BOX 6638 PHOENIX, ARIZONA 85005-6638 (602) 223-2000

“Courteous Vigilance”

ARIZONA DEPARTMENT OF PUBLIC SAFETY

APPLICATION FOR A FINGERPRINT CLEARANCE CARD (non-IVP)

Applicant Clearance Card Team  (602) 223-2279

 Mailing address: P.O. Box 18390, Phoenix, AZ, 85005-8390

 Physical address: 2222 West Encanto Blvd. Phoenix, AZ 85009

TYPE OR PRINT ALL INFORMATION IN BLUE OR BLACK INK. REPRODUCTIONS WILL NOT BE ACCEPTED.

APPLICATION NUMBER

DPS 802-06857 Revised 08-2018

In order for your application to be processed, you MUST check the box or boxes (maximum of 4) to indicate why you are applying.

 DCS-Adoption - ARS § 8-105* $65

 DCS-Foster Home Licensure - ARS § 8-509* $65

 DCS-Field Employee - ARS § 8-802* $67

 DCS-Employee or IT Employee or IT Employees of Contractors or

Subcontractors - ARS § 8-463* $67

 DCS-Child Welfare/Adoption Agency Employee - ARS § 46-141*

 State Board of Pharmacy-Licensure - ARS § 32-1904 $67

 State Board of Pharmacy-3

Party Logistic Providers Representative -

ARS § 32-1941 $67

 DES-Certified Child Care Provider & Non-Certified Relative Provider -

ARS § 41-1964* & ARS § 46-141* $67

 DES-CCR&R Registered Home - ARS § 41-1967.1* $67

 DES-DAAS-Division of Aging & Adult Svcs. - ARS § 46-141*

 DES-DDD/HCBS - Home & Community Based Svcs. - ARS § 36-594.01*

 DES-DDD - Developmental Home Licensure - ARS § 36-594.02* $65

 DES-Employee - ARS § 41-1968* $67

 DES-IT Position - ARS § 41-1969* $67

 DES-Employee or Contractor with access to Federal Tax Information -

ARS § 41-1969* $67

 DES-JOBS Program - ARS § 46-141*

 DES-WIOA-Workforce Innovation & Opportunity Act - ARS § 46-141*

 DES-Domestic Violence/Homeless Shelter - ARS §§ 36-3008 & 46-141*

 DHS-Child Care Group Home; Certification, Employees or Volunteers -

ARS § 36-897.01 & ARS § 36-897.03*

 DHS-Child Care Employees & Volunteers - ARS § 36-883.02*

 DHS-Child Care Facility Licensure - ARS § 36-882* $67

 DHS-Children’s Behavioral Health Programs Employees and Volunteers

ARS § 36-425.03

 DHS-Residential or Nursing Care Institutions; Home Health Agencies -

Employees and Volunteers - ARS § 36-411

 DHS-Nursing Care Administrators & Assisted Living Facility Managers -

ARS § 36-446.04

 DHS-Arizona State Hospital - ARS § 36-207*

 AZ Dept. of Ed-Surrogate Parents - ARS § 15-763.01

 AZ Dept. of Ed-Child Nutrition Programs - ARS § 46-321

 AZ Dept. of Ed-Attend Vocational Program; Age 22 or older

ARS § 15-782.02 $65

 ADOT-Driver Training School Licensure – ARS § 32-2371 $67

 ADOT Traffic School Licensure - ARS § 28-3413 $67

 ADFI-Appraiser-License or Certificate - ARS § 32-3620

 ADFI-Appraisal Management/Registration - ARS § 32-3668

 ADFI-Appraisal Management/Controlling person -

ARS § 32-3669

 ABDE-Dentist Licensure – ARS § 32-1232 $67

 ABDE-Dental Therapist Licensure – ARS § 32-1276.01 $67

 ABDE-Dental Hygienist Licensure – ARS § 32-1284 $67

 ABDE-Denturist Certification – ARS § 32-1297.01 $67

 AZ Board of Fingerprinting-Members & Staff

ARS § 41-619.52* & ARS § 41-619.53* $67

 AZ Charter School Board-Member/Applicant -

ARS § 15-183(C)(4)

 AZ Dept. Real Estate-Licensure - ARS § 32-2108.01 $67

 Department of Juvenile Corrections-Licensee or Contract

Provider - ARS § 41-2814(B)

 Health Science Student & Clinical Assistant

ARS § 15-1881 $65

 Juvenile Probation-Supreme Court, County Attorney or other

Contract Provider Employee or Volunteer - ARS § 8-322

 BTR-Home Inspector Certification - ARS § 32-122.02 $67

 BTR-Controlling Person Certification - ARS § 32-122.05 $67

 BTR-Alarm Agent Certification - ARS § 32-122.06 $67

 AZ Game and Fish - ARS § 17-215*

 AZ Schools for the Deaf & Blind-Superintendent –

ARS § 15-1330 $67

 BPT-Physical Therapist & Assistants Licensure –

ARS § 32-2022 $67

Statutes with a * require a Level One Fingerprint Clearance Card. However, if you qualify, a Level One Fingerprint Clearance card will be issued for any box selected on the application.

 Fee is $67.00 if paid

employee or where noted $67.

 Fee is $65.00 if volunteer

or where noted $65.

Submit fee in form of a money order, cashier’s check, or business check (made payable to “DPS”), or a

State of Arizona Companion Transaction Entry/Transfer. Cash or Personal Checks NOT accepted.

If enclosed payment exceeds amount due, and the overpayment is less than $10.00, signing this application indicates you agree the excess funds can be donated to the Arizona State General Fund.

Fees are subject to change and are not refundable pursuant to ARS § 41-1750(J).

Fill out section below completely – Fields marked with a  are MANDATORY

Your Full Legal Name (Last, First, Middle) - Print clearly

Social Security Number

—

Your Phone Number w/Area Code

Date of Birth

Race

Sex

 Female  Male

Height

Weight

Eye Color

Hair Color

Place of Birth

Applicant’s Complete Mailing Address (Applicant’s address only) - Print clearly

City

State

Zip Code

Name of Employer and/or Agency - Print clearly (If unknown or student leave blank)

Employer’s Phone Number w/Area Code

Employer and/or Agency Mailing Address - Print clearly

City

State

Zip Code

Applicant’s e-mail address - Print clearly

Applicant’s Signature **

Date

** I authorize custodians of records to release information to the AZ DPS to process my application and acknowledge I have read the “Notice to Applicant”.

*WF51003949*