ARIZONA DEPARTMENT OF PUBLIC SAFETY

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

“Courteous Vigilance”
DOUGLAS A. DUCEY FRANK L MILSTEAD
Governor Director

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 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.

DPS 802-06857 Rev. 6-2019

 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 YOUR 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. The employers address and applicants address cannot be the same, if it’s the same then you must indicate
you work where you live.
• 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 being 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 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
Birth 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 OF THE FOLLOWING ITEMS TOGETHER TO 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 ADOT - AZ Department of Transportation
DES - Department of Economic Security ADFI - AZ Department of Financial Institutions
DHS - Department of Health Services ABDE - AZ Board of Dental Examiners
BPT - Board of Physical Therapy BTR - Board of Technical Registration
GO TO THE NEXT PAGE AND READ THE “NOTICE TO APPLICANT” INFORAMTION BEFORE YOU FILL OUT THE APPLICATION

DPS 802-06857 Rev. 6-2019

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

“Courteous Vigilance”
DOUGLAS A. DUCEY FRANK L MILSTEAD
Governor Director

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
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”

DPS 802-06857 Rev. 6-2019

 APPLICATION NUMBER
ARIZONA DEPARTMENT OF PUBLIC SAFETY
APPLICATION FOR FINGERPRINT CLEARANCE CARD (non-IVP) *Your Application Number will
Applicant Clearance Card Team  (602) 223-2279 generate when you print this page.
 Mailing address: P.O. Box 18390, Phoenix, AZ 85005-8390 Printing multiple copies WILL result in
 Physical address: 2222 W. Encanto Blvd., Phoenix, AZ 85009 duplicate applications.*
TYPE OR PRINT ALL INFORMATION IN BLUE OR BLACK INK. REPRODUCTIONS WILL NOT BE ACCEPTED.

Fill out section below completely - Fields marked with a  are MANDATOR
Your Full Legal Name (Last, First, Middle) Social Security Number  Your Phone Number

Date of Birth (mm/dd/yyyy) Race Sex Height Weight Eye Color Hair Color Place of Birth
 Female  Male
Applicant’s Complete Mailing Address (Applicant’s address only) City State Zip Code

Name of Employer and/or Agency (if unknown or student leave blank) Employer’s Phone Number

Employer and/or Agency Mailing Address City State Zip Code

Applicant’s E-mail Address 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”

 Fee is $67.00 if paid employee  Fee is $65.00 if volunteer Submit fees in form of money order, cashier’s check, or Business Check with pre-printed business address (made
payable to “DPS”), or a state of Arizona Companion Transaction Entry/Transfer. Cash or personal checks NOT accepted.
or where noted $67 or where noted $65.
If the payment enclosed exceeds the amount due and the overpayment is $10.00 or less, by signing this application you agree to have the excess funds donated to the State General Fund.
Fees are subject to change and are not refundable pursuant to ARS § 41-1750(J).
In order for your application to be processed, you MUST check the box or boxes (all that apply) to indicate why you are applying.

 DCS-Adoption - ARS § 8-105* $65  AZ Dept. of Ed-Child Nutrition Programs - ARS § 46-321
 DCS-Foster Home Licensure - ARS § 8-509* $65  AZ Dept. of Ed-Attend Vocational Program; Age 22 or older -
 DCS-Field Employee - ARS § 8-802* $67 ARS § 15-782.02 $65
 DCS-Employee or IT Employee or IT Employees of Contractors of  ADOT-Driver Training School Licensure - ARS § 32-2371 $67
Subcontractors - ARS § 8-802* $67
 ADOT-Traffic School Licensure - ARS § 28-3413 $67
 DCS-Child Welfare/Adoption Agency Employee - ARS § 8-105*
 State Board of Pharmacy-Licensure - ARS § 32-1904 $67
 ADFI-Appraiser-License or Certificate - ARS § 32-3620
 State Board of Pharmacy-3rd Party Logistic Providers Representative -  ADFI-Appraisal Management/Registration - ARS § 32-3668
ARS § 32-1941 $67  ADFI-Appraisal Management/Controlling Person - ARS § 32-3669
 DES-Certified Child Care Provider & Non-Certified Relative Provider -  ADBE-Dentist Licensure - ARS § 32-1232 $67
ARS § 41-1964* & ARS § 46-141* $67
 DES-CCR & R Registered Home - ARS § 41-1967.1* $67
 ADBE-Dental Therapist Licensure - ARS § 32-1276.01 $67
 DES-DAAS-Division of Aging & Adult Services - ARS § 46-141*  ADBE-Dental Hygienist Licensure - ARS § 32-1232 $67
 DES-DDD/HCBS - Home & Community Based Services - ARS § 36-594.01*  ADBE-Denturist Certification - ARS § 32-1297.01 $67
 DES-DDD - Developmental Home Licensure - ARS § 36-594.02* $65  AZ Board of Fingerprinting-Members & Staff -
 DES-Employee - ARS § 41-1968* $67 ARS § 41-619.52* & ARS § 41-619.53* $67
 DES-IT Position - ARS § 41-1969* $67  AZ Charter School Board-Member/Applicant - ARS § 15-183(C)(4)
 DES-Employee or Contractor with access to Federal Tax Information -  AZ Dept. of Agriculture-Industrial Hemp License - ARS § 3-314
ARS § 41-1969* $67
 DES-JOBS Program - ARS § 46-141*
 AZ Dept. Real Estate-Licensure - ARS § 32-2108.01 $67
 DES-WIOA-Workforce Innovation & Opportunity Act - ARS § 46-141*  Department of Juvenile Corrections-Licensee or Contract Provider -
ARS § 41-2814(B)
 DES-Domestic Violence/Homeless Shelter - ARS § 36-3008 and § 46-141*
 DHS-Child Care Group Home; Certification, Employees or Volunteers -  Health Science Student & Clinical Assistant - ARS § 15-1881 $65
ARS § 36-897.01 & ARS § 36-897.03*  Juvenile Probation-Supreme Court, County Attorney or other Contract
 DHS-Child Care Employees & Volunteers - ARS § 36-883.02* Provider Employee or Volunteer – ARS § 8-322
 DHS-Child Care Facility Licensure - ARS § 36-882* $67  BTR-Home Inspector Certification - ARS § 32-122.02 $67
 DHS-Children’s Behavioral Health Programs Employees and Volunteers -  BTR-Controlling Person Certification - ARS § 32-122.05 $67
ARS § 36-425.03
 BTR-Alarm Agent Certification - ARS § 32-122.06 $67
 DHS-Residential or Nursing Care Institutions; Home Health Agencies -
Employees and Volunteers - ARS § 36-411  AZ Game and Fish - ARS § 17-215*
 DHS-Nursing Care Administrators & Assisted Living Facility Managers -  AZ Schools for the Deaf & Blind-Superintendent – ARS § 15-1330 $67
ARS § 36-446.04
 BPT-Physical Therapist & Assistants Licensure – ARS § 32-2022 $67
 DHS-Arizona State Hospital - ARS § 36-207*
 AZ Dept. of Ed-Surrogate Parents - ARS § 15-763.01
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.

DPS 802-06857 Rev. 05-2019 CS-368707924-V1