Page 1 of 3 ITCD-96B GENERAL REGISTRATION FORM
MAY 2020
STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
INFORMATION TECHNOLOGY AND COMMUNICATIONS DIVISION
CRIMINAL JUSTICE INFORMATION SYSTEM - CENTRAL REPOSITORY (CJIS-CR)
APPLICATION TO RECEIVE CRIMINAL HISTORY RECORD INFORMATION
FOR EMPLOYMENT OR LICENSING PURPOSES
PART I. AGENCY CONTACT INFORMATION
Name of Agency:
Agency Street Address:
City:
State:
Zip Code:
Agency Point of Contact:
Agency Point of Contact’s Position/Title:
Mailing Address:
City:
State:
Zip Code:
Business Phone:
Ext:
Fax:
Email Address:
Is your agency a governmental agency? Yes (please complete Part III ONLY) No (please complete Parts II and III)
PART II. GOVERNMENTAL AGENCY CONTACT INFORMATION
If you answered ‘Yes’ in Part I, please provide the name of the contact person from the governmental agency
that has employment/licensing authority over your agency.
List the statutory (legal) authority that authorizes your agency to receive federal criminal history information:
(ex. Criminal Procedure Article, §10-236.3, Annotated Code of Maryland) _________________________________________
Governmental Agency Name:
Governmental Agency Point of Contact:
Governmental Agency Primary Point of Contact’s Position / Title:
Street Address:
City:
State:
Zip Code:
Email Address:
Business Phone:
Ext:
Page 2 of 3 ITCD-96B GENERAL REGISTRATION FORM
MAY 2020
PART III. REASON FOR REQUEST
Only one (1) request type should be checked; checking more than one (1) request type will result
in a delay in processing this application.
CHILD CARE
Copy of License/Certification required at time of application.
Maryland programs ONLY, pursuant to Family Law Article, §5-551, Annotated Code of Maryland; entitled to state criminal history record
information only. Federal criminal history record information may only be disseminated to a governmental agency.
1. Child Care center required to be licensed by the Maryland State Department of Education - Office of Child Care
Administration. Please identify Child Care Region.
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7
Region 8 Region 9 Region 10 Region11 Region 12 Region 13
2. Family Child Care home or large family Child Care home required to be registered by the Maryland State
Department of Education - Office of Child Care Administration. Please identify Child Care Region.
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7
Region 8 Region 9 Region 10 Region11 Region 12 Region 13
3. Child Care home required to be licensed by the Department of Human Services or Maryland Department of Juvenile
Services.
4. Child Care institution required to be licensed by the Department of Human Services or Maryland Department of
Juvenile Services.
5. Juvenile detention, correction, or treatment facility operated by the Maryland Department of Juvenile Services.
6. A public school as defined in Title 1 of the Education Article.
7. Private or nonpublic school with a certificate of approval from the Maryland State Department of Education; required
to report annually.
8. Department of Human Services foster care family home or group facility.
9. Recreation center or recreation program operated by the State primarily serving minors.
10. Recreation center or recreation program operated by a local government primarily serving minors.
11. Recreation center or recreation program operated by a private entity primarily serving minors.
12. Day or residential camp primarily serving minors that is licensed by the Maryland Department of Health.
13. Home health agency or residential service agency providing home or community-based health services for minors
licensed by the Maryland Department of Health.
14. A contractor or subcontractor having employees that will have direct, unsupervised, and uncontrolled access to
children in a facility listed Sections 1-12 of this application.
15. An employer at a facility not identified in sections 1-12 of this application who employs individuals to work with
children.
Page 3 of 3 ITCD-96B GENERAL REGISTRATION FORM
MAY 2020
ADULT DEPENDENT CARE
Copy of License/Certification required at time of application.
(Maryland programs ONLY, licensed or regulated by Maryland Department of Health; entitled to STATE Criminal History Record Information ONLY)
5. Residential Service Agency
6. Congregate Housing Services
Program
7. Alternate Living Unit
8. Hospice Facility
9. An organized institution, environment, or home that
maintains conditions or facilities and equipment to provide
domiciliary, personal, or nursing care for two or more
unrelated individuals who are dependent on the
administrator, operator, or proprietor for nursing care or
the subsistence of daily living in a safe, sanitary, and
healthful environment; and admits or retains the individuals
for overnight care.
GOVERNMENT EMPLOYMENT or LICENSING
Government Employment: Criminal Justice Federal State Local
Government Licensing/Certification: (Note: Copy of License/Certification required at time of application.) State Local
ATTORNEY/CLIENT
(Entitled to STATE Criminal History Record Information ONLY)
Attorney/Client
PART IV. AUTHORIZED SIGNATURE
Application invalid unless signed below.
I certify, under penalty of law, that the statements made herein are true and correct to the best of my knowledge, information, and belief.
I certify that in the event this Application is approved, I will submit record check requests to the CJIS -CR only for employees,
prospective employees, licensees, and/or applicants for licenses. Criminal history record information (CHRI) received as a result of this
approved Application may only be used for the purpose with which it was requested and in accordance with applicable Federal and State
laws and regulations. I further understand that any criminal history record information received is not to be disseminated (shared) with
any other person and/or agency.
The Applicant agrees to indemnify and hold harmless the Maryland Department of Public Safety and Correctional Services, its employees
and officials from any claim, demands, actions, suits, and proceedings brought by others against the Applicant arising from this Application,
which are founded upon the negligence or other tortuous conduct of the Applicant.
____________________________________________________ _______________________
Signature Date
________________________________________________________________________________
Title
PART V. SUBMISSION INSTRUCTIONS
Completed and signed applications should be submitted via email to: dlcjiscustomerservice7_dpscs@maryland.gov
Please attach a brief description of your agency.
Please include applicable licensing and/or certification.
Please note that submitting this application through other means (mail, hand delivery, etc.) may cause a delay in processing
the application.
FOR INTERNAL AGENCY USE ONLY – DO NOT WRITE BELOW THIS LINE.
Adult Dependent Care
Attorney/Client: State Only
Child Care: Full State Only
Government Employment: Criminal Justice Full State Only
Government Licensing/Certification: Criminal Justice Full State Only
Agency description attached
Certification attached
License attached
Approved
Denied
Pending—
Application Incomplete
Reviewer’s Initials:
Review Date:
Application Expiration Date: