Authorization for Review of Criminal History Information
I, __________________________________________________ do hereby authorize the ACIC to
(Type or Clearly Print Full Name of Requesting Party – First, Middle, and Last names)
review and discuss with me any records pertaining to me that may exist in the state or national criminal
history record systems. Or, my records may be discussed with the following person specifically
authorized to be my designee: ______________________________________ __________________
(Type or Print Name of Designee) (Phone Number)
_________________________________________________ __________________ ______________________
(Signature of Requesting Party) (Date) (Phone Number)
Acknowledgement and Verification:
The above requesting party, known by me to be the person identified, did appear before me this
_________ day of _________________, 20____, to sign and execute this request.
____________________________________________
(Signature of Notary Public)
_________________ ______________________
(County) (Expiration of Commission)
Form Revised 06/06/2019
Arkansas law (A.C.A. § 12-12-1013) provides that a person, upon positive verification of his or her identity, may review criminal history information
compiled, maintained and accessible through the Arkansas Crime Information Center. A criminal history record may only be reviewed by the subject,
the subject’s attorney or other person authorized in writing by the subject. To initiate such a review, this form should be completed and returned to the
Arkansas Crime Information Center, Criminal History Division, 322 S. Main Street, Ste. 615, Little Rock, AR 72201, or faxed to 501-682-2269.
Date of Birth: ____________ Race: ________
Sex: _____________
Social Security Number ____________________
*(SSN is voluntary, but is helpful for identification)
Please list all previous names used:
___________________________________
___________________________________
___________________________________
Please mail a copy of the record to the following address:
(Name of Requesting Party or Designee)
(Address)
(City) (State) (Zip)
***COMPLETE IN PRESENCE OF NOTARY***
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