(department or Company Name) agrees to pay for the cost of fingerprint/background and or driver’s license checks for the following individual(s): 

(please check services required:  fingerprint/Criminal History driver’s license

NAME(S)     (DOB)              

The company or department of would like to schedule this process for (time) on (date)   

  (1).  We understand that it may take up to 10 business days to get the written results back on fingerprints.  We also understand that should a fingerprint result come back as “flagged”

  (2), the individual will not be cleared to work until the situation is resolved.   We further understand that the physical address of the individual (home residence)

  (3) will determine whether an in-state or national fingerprint search will be conducted.  Charges for individuals residing at current home address for a period of less than five years will be at a higher fee.

Billing Arrangements:

I.  University Department: 

(SAP NUMBER)  

 (Fund- 7)(Cost Center-10)(Functional Area – 1)(G/L Commitment Item No.-6)

Authorization Name:  (title)

Who the Notification Results Will Be Sent To:

(Name and mail location)

II.     Outside Department/Company Information:

Name:

(EIN Number/Provider Number at University)

Billing Address:

Responsible Person:
Phone: (555-555-5555)

Email:

Fax: (555-555-5555)

Name and Address of Person Receiving Results Notification:

Please print this form and take it with you to Three Edwards.

Payment by credit card can be completed in person only.

(1) Fingerprinting is done Monday through Friday 10 am to 3 pm unless special arrangements are made.

(2) A “flagged” fingerprint check is an electronic notification to Public Safety that a situation exists in the background of the individual which warrants further explanation.  Please note that it will take 7 to 10 business days to receive this information through the mail.  

(3) In State fingerprint/Background checks are run for individuals who have lived within the state of Ohio for the past 5 years.  National fingerprint/Background checks are run on individuals who live or have lived outside of the State of Ohio within the past 5 years.  Proof of identity and permanent home address must be provided.  (Driver’s License, State ID card)

*** In-State fingerprint Charge:    $32.00

     National Fingerprint Charge:  $34.00

     Driver’s License Charge:        $ 3.00

After processing the billing form, a copy will be sent to the person requesting the service.  Individuals requesting the service will be given a receipt to show payment.