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)