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
___________________________________________________
Signature
__________________
Date
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Special employment provisions (check if applicable):
Employment with cri
minal justice agency – civilian (Purpose code ‘J’)
Employment with criminal justice agency – P.O.S.T. certified (Purpose code ‘Z’)
One of the following must be checked:
This authorization is valid for 90 / 180 /_____ (check one) days from date of signature.
I, _______________________________________________ give consent to the above
named to perform periodic criminal history background checks for the duration of my
employment with this agency.
Fulton County Department of Emergency Services, E911
