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Schedule Appointment

By DevOps Digityza / February 16, 2024

STATE OF MARYLAND
Department of Public Safety and Correctional Services
Information Technology and communications Division

Criminal Justice Information System - Central Repository (CJIS-CR)

APPLICANT INFORMATION

Name:

Date of Birth:

Social Security Number:

Gender:

Male Female

Height:

Weight:

Eye Color:

Hair Color:

Race/Ethnicity:

Black White Asian/Pacific Islander Native American Other

Place of Birth:

Citizenship:

Street Address:

City:

State:

Zip Code:

Phone Number:

Driver’s License Number:

Email Address:

REASON FOR REQUEST

INDIVIDUAL

Please select one of the following:

Gold Seal/Adoption (Enter Authorization Number if applicable) Gold Seal/Letter/VISA Immigration/VISA Individual Challenge Individual Review Attorney/Client (Written Authorization Required)

Mailing Information:

Name:

Street Address:

City:

State:

Zip Code:

AGENCY

Please select from the following (*ORI Required):

Adult Dependent Care Child Care* Criminal Justice*

Government Employment* Government Licensing or Certification* Maryland State Police Licensing*

Private Party Petition** Public Housing

Agency Authorization Number:

*ORI Number:

**Position Applied:

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(240) 353-7622
(240) 393-0864
[email protected]
3901 Perthshire Place Upper Marlboro, MD 20772

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