Fillable Consent Form for GCIC/NCIC Records Check (City of South Fulton)

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Consent Form for GCIC/NCIC Records Check (City of South Fulton)

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The Consent Form for GCIC/NCIC Records Check (City of South Fulton) form is 1 page long and contains:

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  • 4 check-boxes
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Country of origin: US
File type: PDF

U.S.A. forms for City of South Fulton

BROWSE CITY OF SOUTH FULTON (GA) FORMS

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Created 3/10/2020
South Fulton Police Department
5440 Fulton Industrial Blvd · Atlanta, Georgia 30336
Phone: (470) 809-7300
Keith Meadows
Chief of Police
Consent Form for GCIC/NCIC Records Check
I authorize the SOUTH FULTON POLICE DEPARTMENT to receive any criminal history
record information pertaining to me, which may be in the files of any federal, state, and/or city
criminal justice agency in Georgia.
The agency must advise you of the procedures for changing, correcting, or updating your criminal history record as
set forth in Title 28, Code of Federal Regulations (CFR), Section 16.34.
In the event an adverse employment or licensing decision is made, you must be informed of all information pertinent
to that decision to include the contents of the record and the effect the record had upon the decision. Failure to
provide all such information to the person subject to the adverse decision shall be a misdemeanor [O.C.G.A. § 35-3-
34(b) and §35-3-35(b)].
I, _____________________________________, confirm that I have received a copy of the Privacy
Rights Act Statement for Criminal Justice Employment. I further confirm that I have read and understand
the guidelines listed in the Privacy Act Statement for Non-Criminal Justice Purposes.
DATE: _______________________________________________________________________
PRINT FULL NAME: ___________________________________________________________
MAIDEN NAME/PREVIOUS NAME/ALIAS INFO: __________________________________
ARE YOU A U.S. CITIZEN? YES_______ NO______
If no, you will need to have your Green Card available. Country of Birth _______________
DATE OF BIRTH _______________ RACE_______SEX ______SOCIAL SEC# ___________
STREET ADDRESS ____________________________________________________________
CITY __________________COUNTY _______________STATE_________ZIP____________
SIGNATURE OF APPLICANT ___________________________________________________
CIS TECH: _________________________DATE COMPLETED: ________________________
RECORD ATTACHED: _________________NO RECORD: ___________________________
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Consent Form for GCICNCIC Records Check (City of South Fulton)

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Completed 2 August 2020

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