Created 2/26/2020
South Fulton Police Department
5440 Fulton Industrial Blvd · Atlanta, Georgia 30336
Phone: (470) 809-7300
Keith Meadows
Chief of Police
CRIMINAL HISTORY RECORD CHECK
CONSENT FORM
I hereby authorize a City of South Fulton Police Department certified CJIS technician to conduct an
inquiry and receive any Georgia criminal history record information pertaining to me which may be
contained in the files of any state or local criminal justice agency in Georgia.
_____________________________________________________________________________
Full Name (print)
_____________________________________________________________________________
Street Address City State Zip Code
_____ _____ __________________ _________________________
Sex Race Date of Birth Social Security Number
______________________ ________________ ___________________
Signature Date Phone #
Purpose of Request:
Personal Inspection/Employment (E)
Personal Inspection (U) **upon requestor or attorney only**
Adoption (E)
Employment with mentally disabled (M)
Employment with elder care (N)
Employment with children (W)
Public Records- Felony convictions only (P)
Requestor’s Name: ____________________________
** THIS AUTHORIZATION IS VALID FOR THIRTY (30) DAYS FROM DATE OF SIGNATURE**
________________________________ __________________
City of South Fulton certified technician Date
click to sign
signature
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