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Sample Fingerprint Record Notification Form

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Reviewed Date: December 12, 2019

Original Author: 
Hardy, Pat
Date of Material: 
Aug 21, 2018


Sample Fingerprint Record Notification Form

MTAS created a sample fingerprint record notification form to be used with municipal employees in departments other than law enforcement. The required federal privacy act statement is also included and should be provided along with the notification form.

[Name or town or city] Privacy Act Requirements
Notifications to Applicants required to have a National Fingerprint Record-Check
Authorized governmental agencies that conduct a national fingerprint-based criminal history record check on an applicant for a noncriminal justice purpose are obligated to ensure the applicant is provided certain notices and other information. This document complies with such requirements.
The applicant is hereby notified:

  • Your fingerprints will be used to check your criminal history records.
  • You have received, and your signature below acknowledges, the attached Privacy Act Statement, which is dated 3/30/2018.
  • You have the opportunity, within 10 days, to challenge in writing the accuracy of the information in the record.
    • Corrections to the record must be made within 60 days of the date of this notification, and you will not be denied a license based on information in the record until such 60 days has passed, unless you decline to make corrections.
    • Procedures for obtaining a change, correction, or update of a criminal history record are set forth in 28 CFR 16.34.
  • The [City/Town of …] will use the record solely for the purpose of ________________ (specify liquor license, beer license, taxi cab license, dispatcher, etc.).
  • The [City/Town of …] will not disseminate the record outside the receiving department.

As the undersigned I have read and understand the notifications described above. I have also received a copy of the Federal Privacy Act Statement.
___________________________________________________________                               _________________
                                             Signature of Applicant                                                                               Date


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Information written by MTAS staff was based on the law at the time and/or a specific sets of facts. The laws referenced may have changed and/or the technical advice provided may not be applicable to your city or circumstances. Always consult with your city attorney or an MTAS consultant before taking any action based on information posted to this website.