Important: This form must be hand signed. No electronic signatures. All pages of this form must be uploaded to your submission page.

This form allows us to pull down existing fingerprints in the AHCA System or to Initiate a new screening. After you sign and date this form we will find your fingerprints in the AHCA system. If you do not have fingerprints in the AHCA system we will initiate a new screening. We will send you a list of locations near you that provide this service. In addition, we will send you an L2 request form with an ORI number you will take to your fingerprinting appointment.

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8001 Beaty Grove Dr.

Tampa, FL 33626

Office: 813.926.5454


Fax:     813.920.9252

5810 Shelby Oaks Dr. Suite B

Memphis, TN 38134

Office: 901.295.2523

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