CertifiCation and authorization form
for a Criminal history
Directions: Please complete all of the sections on this form.
Maiden Name (if applicable)
Street or P.O. Box
3. E-mail Address:
(You MUST use the mailing address on file as it appears on the Form U4. If this address is not current, please amend your
as soon as possible so that there is no delay in the background check process.)
4. Date of birth
7. Social Security number
Female 6. Daytime telephone number
(Include area code)
8. Individual CRD or state registration number
9. Have you completed the fingerprinting process by IDEMIA or MorphoTrust for the New Jersey Bureau of Securities or
Division of Consumer Affairs since May 2012?
If “Yes,” please provide the date on which you were fingerprinted: