CRIMINAL RECORD INFORMATION REQUEST
In accordance with Code of Federal Regulations 28CFR20.21, Code of Virginia § 9.1-101, Code of
Virginia § 19.2-389 (1950), as amended, and the Rules and Regulations of the Criminal Justice
Services Commission of the Commonwealth of Virginia.
1. Unauthorized or further dissemination will subject the disseminator to crim
inal and civil penalties.
2. This form will be placed on file and remain on file for at least two (2) years (Code of Virginia).
(Please PRINT on application except for signatures required)
Applicant Information (name searched):
Last Suffix Full First Name Full Middle Name Maiden
Sex Date of Birth SS# _______________________
Place of Birth
Reason for Request _______________________________________
Current Address __________________________________________________________________________________
Street #/Street Name Apt# City State Zip
Phone ( ______ )__________________________
(Include Area Code)
Applicant Notarization: I hereby give consent and authorize the Virginia Beach Police Department to search
their files and Virginia Central Criminal Records Exchange (CCRE) for any criminal history record and report the
results of such search to the agent or individual authorized in this document to receive same.
Signature of Person Named in Record ________________________________________________________________
Subscribed and sworn to/affirmed before me this ____________ day of __________________________ , 20 ________
My commission expires _____________________
Requesting Division: As provided for in Section 19.2-389, Code of Virginia, I hereby request the criminal history
record of the individual named in Section I above and swear or affirm that I have the consent of the person to
obtain his/her record and will not further disseminate the information received, except as provided by law.
Signature of Person Making Request _____________________________________________ Date: _________________
___ No Criminal Record
Clerk's Signature: ___________________________Code:________
___ Positive Criminal Record
Position (volunteer, college intern, Project Lifesaver, CAC, A/C, other): _______________________________
Approved By: _______________________________ Work Location: ________________________________
ID Printed By: _______________________________ Date: _______________ ID Expiration: ____________
(Return completed form to the VBPD Volunteer Resource Manager’s Office)
Below For Office Use ONLY