Form: MLA01
Rev. 04/07/2016
AUTHORITY FOR RELEASE OF INFORMATION
State and Federal Record Check
I, the undersigned, hereby authorize the North Carolina Department of Justice through the State Bureau of
Investigation, Division of Support Services, to perform a fingerprint search of the State’s criminal history
record file and a fingerprint search of the Federal Bureau of Investigation’s files for a national criminal
history record check pursuant to the provisions of NCGS 53-244.050, in connection with my application for
license under the provisions of Article 19B of Chapter 53 (North Carolina Secure and Fair Enforcement
Mortgage Licensing Act (“NC SAFE Act”)) from the Office of the Commissioner of Banks.
Further, I understand that the North Carolina State Bureau of Investigation, Division of Support Services,
and its officials and employees, shall not be held legally accountable in any way for providing this
information to the Office of the Commissioner of Banks, and I hereby release said agency and persons from
any and all liability which may be incurred as a result of furnishing such information. I further understand
that the Office of the Commissioner of Banks cannot provide a hard copy of the results of this criminal
history record check to me.
Print legibly or Type
NMLS ID No.:
Name:
Last, First, Middle, and Maiden (if applicable)
Sex (Circle One): M F
Race:
Date: ________________________________________
Signature
The Office of Commissioner of Banks shall retain this form for a period of 12 months from the date of
electronic submission of the application, and it shall be furnished to the State Bureau of Investigation upon
request.
ORI # BANKS0001- Office of the Commissioner of Banks
SBI Fingerprint Card Check -- $14.00
FBI Fingerprint Card Check -- $24.00
_____________________________________
Total -- $38.00 (Non-refundable)
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