Georgia Bureau of Investigation Georgia
Crime Information Center
Consent Form
I hereby give my consent for the _____________________________________________
(Criminal Justice Agency)
to receive any Georgia or III criminal history record information pertaining to me, as authorized
under state and federal law for individuals seeking employment with a criminal justice agency.
Full Name (print)
Address
Sex
Race
Date of Birth
Social Security Number
Signat
ure
CRIMINAL HISTORY CONSENT FORM
Department of Human Resources
141 Pryor Street SW,
Atlanta GA 30303
(404)-612-4000
Date
---------------------------------------------------------------------------------------------------------------------
Special employment provisions (check if applicable):
Employment with criminal justice agency – civilian (Purpose code ‘J’)
Employment with criminal justice agency – P.O.S.T. certified (Purpose code ‘Z’)
On
e of the following must be checked:
This authorization is valid for 90 / 180 days from date of signature.
I, ______________________________________________________ give consent to the
above named I,to perform periodic criminal history background checks for the duration of my
employment with this agency.
