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Maryland Lottery and
Gaming Control Agency 		LiveScan Registration Form
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This LiveScan Registration Form is designed to facilitate an expeditious fingerprinting experience for your Maryland Lottery and Gaming Control Commission gaming-related license application.

Your fingerprints will be used to check the criminal history records maintained by the Maryland Criminal Justice Information System (MD CJIS) and the Federal Bureau of Investigation (FBI). The use of the MD CJIS and FBI criminal history record information will be used to assist in the determination of suitability for the issuance of a Maryland video lottery employee license.

Complete each section below. Once completed, present the Registration Form and an acceptable proof of identity* to the Maryland Lottery and Gaming Control Agency Representative who will then complete your fingerprinting.

You must make accurate statements. Any misrepresentations, failure to provide any requested information, or failure to meet any of the requirements as set out in the law or regulation may result in the denial of your license application and may subject you to civil and/or criminal penalties.


 
Name
Last Name:
First Name:
Middle Name:
Suffix:
select
Maiden Name:
 
Alias
Last Name:
First Name:
Middle Name:
 
Place of Birth
Birth Date:
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Country:
select
City/Town:
State/Province/Region:
select
 


Information
Social Security #:
Height: (FT) (IN)
Weight:
Hair Color:
select
Eye Color:
select
Race:
select
Other (Race):
Drivers License #:
Drivers License State:
select
Country of Citizenship:
select
   


 
Current Residence
Country:
select
Address 1:
Address 2:
City/Town:
State/Province/Region:
select
Postal Code:
Daytime Phone: Evening Phone:
 
Employment
Employer:
Country:
select
Address 1:
Address 2:
City/Town:
State/Province/Region:
select
Postal Code:
 

*Acceptable proofs of identity include any photo identification card issued by a United States Governmental Agency, examples include: a Maryland driver's license, a driver's license issued by another state, the District of Columbia; a United States passport; a certificate of United States citizenship; a certificate of naturalization; an alien registration card; a United States military identification card; an identificate card issued by a State or local governmental agency or the District of Columbia.

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