Please note: Form options are set by the State of Michigan. You must have JavaScript enabled to use this form. Contact Name Please type name as it appears on legal documents/driver's license/state ID, etc. with full middle name. First Middle Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Email Biometrics Date of Birth Place of Birth State or Country Race - Select -American Indian or Alaskan NativeAsian or Pacific IslanderBlackIndeterminable or UnknownWhite or Latino Gender - Select -MaleFemaleUnknown Height Height: Feet feet Height: Inches inches Weight Eye Color - Select -BlackBlueBrownGrayGreenHazelUnknown Hair Color - Select -BaldBlackBlond or StrawberryBrownGrayRed or AuburnWhiteUnknown Reason and Affirmation Driver's License/State ID Number Reason for Fingerprint Scan Which program you are entering? - Select -NursingDentalOccupational Therapy AssistantRadiologic TechnologyCertified Nurse AideMedial AssistantFaculty I affirm that all the above information is accurate and complete. I understand that any falsification, misrepresentation or omission herein may result in refusal of, or immediate dismissal from the health programs at GRCC.I give the GRCC Police Department permission to share any information received through my fingerprints with the Health program director, assistant dean and/or appropriate clinical facilities.The current cost of finger-printing is $63.00 via RaiderCard transaction or you may pay at the Student Financial Services office (first floor of Raleigh J. Finkelstein Hall) and bring the receipt to the GRCC Police department when you go in for your appointment.Any request to cancel the finngerprint scan after the prints have been transmitted will not result in any refund.Please note: Falsification of information is a criminal offense and will be investigated as a crime. Signature Please type your full name. Today's Date