Agency . . . . | |
Agency No . . . . | |
Date . . . . | |
Time . . . . | |
I, . . . . . . . . . . . . , do hereby request to inspect my criminal history record information maintained in the files of the above named agency. In order to ensure positive identification as the person in question, I am submitting my fingerprints in the space below. | |
(Fill in where applicable box) | |
Because I am unable to read □; do not understand English □; other reason □; I hereby designate and consent that (Print Name) , whose address is . . . . . . . . . . . . . . . . , read or otherwise described or translated to me the criminal history record information concerning myself. | |
. . . . . . . . | |
Prints of right four fingers taken simultaneously | (Signature or mark of Applicant) . . . . |
(Address) . . . . | |
. . . . (Signature of Designee) | |