FINGER PRINT / BACKGROUND CHECK

THERE IS A NONREFUNDABLE FEE OF $50

Apart of your acceptance into this Hillsborough Community College program, you
will need to submit to a criminal background check.

Complete the attached form and bring it to the HCC Ybor City Campus,
YPST building (2002 N 17th St, Tampa, Fl 33605).

Finger prints are done Monday through Friday from 9:00 a.m. to 3:00 p.m.,
excluding HCC holidays.

Applicants must bring a picture ID (drivers license or student ID).

Make your $50 check or money order out to Hillsborough Community College, or
too HCC. NO CASH OR DEBIT CARDS ARE ACCEPTED.

The results of your background check will not be sent to you, but forwarded to
your programs department.

Criminal Justice Institute 5/29/13

 THERE IS A NONREFUNDABLE FEE OF $50

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Transaction Information
Programs
Fire Child Care Senior Helpers Law 911 Nursing EMT Paramedic Health Care
Dental
Nuclear medicine
Radiography
Respiratory
Sonography
Personal Information
Last Name First Name Middle Name

Social Security Number Date of Birth

Place of Birth Country of Citizenship

Current Street Address Apt#

City State Zip code

(area code) day time telephone Email Address

Drivers License Number Student ID number

Physical Descriptors
Gender Race Color Eyes Hair Color Height Weight
Male Oriental/Asian Black Bald
Female Black Blue Black
unknown American Indian/Alaskan native Brown Blonde or strawberry
White (includes Mexicans) Green Blue
Unknown Gray Brown
Hazel Green
Maroon Gray or partially gray
Multicolored Orange
Pink Purple
Unknown Red or Auburn
Sandy
White
Unknown
OFFICE USE ONLY
I confirm that the above information is true and that I have reviewed all of the information that is to be
submitted to the Florida Department of Law Enforcement (via Cross Match Live Scan). I agree that if the
information is submitted incorrectly, that I will pay the cost of the additional transaction.
DO NOT SIGN UNTIL TOLD TO

Signature:_______________________________________ Date:__________

Criminal Justice Institute 5/29/13