Agency . . . .

Agency No . . . .

Date . . . .

Time . . . .

I, . . . . . . . . . . . . , request to inspect my criminal history record information maintained in the files of the above named agency.

I was born (Date of Birth) , in (Place of Birth) , and to ensure positive identification as the person in question, I am willing to submit my fingerprints in the space provided below, if required or requested.

(Fill in and check applicable box)

Because I am unable to read □; I do not understand English □; otherwise need assistance in reviewing my record □; I designate and consent that (Print Name) , whose address is . . . . . . . . . . . . . . . . , assist me in examining the criminal history record information concerning myself.

. . . .

. . . .

Prints of right four fingers

taken simultaneously

(Signature or mark

of Applicant)

. . . .

 

(Address)

. . . .

 

. . . .

(Signature of Designee)