Date: ________________________________ Position Applied For: ___________________________________________
Print Full Name: _________________________________________________________________________________________
List Any Other Names Used: ____
___________________________________________________________________________
(Alias, Maiden, Nickname, etc.)
Race: ___________________ Sex: _____________ D.O.B.: _________________ Place of Birth: _____________________
SSN: ______________________________________ Driver’s License No.: ________________________________________
State of Issue: ______________________________ Class Type: ____________________ Expiration: ________________
Height: _________________ Weight: ____________ Eye Color: ___________________ Hair Color: _________________
Address: ______________________________________________________________________________________________
City: ___________________________________________ State: ________________________ Zip: ____________________
Home Phone: ___________________________________ Other Phone(s): _________________________________________
List on the line directly below all states in which you have been issued a driver’s license:
_________________________________________________________________________________________________________
List on the line directly below all states in which you have lived:
_________________________________________________________________________________________________________
****************************************---------------------------------------------**************************************
| OFFICAL USE ONLY |
DO NOT WRITE BELOW THIS LINE
Terminal Operator, please check criminal history records for the following reason:
Driver License History
Miscellaneous Request
Requested by: ____________________________________________________________________________________________
Print Name
Signature
Comment: ______________________________________________________________________________________________
OPS09
NCIC/GCIC HISTORY REQUEST
Fulton County Sheriff's Office
Background Investigation Section
185 Central Ave S.W., 9th Floor
Atlanta, GA 30303
404-612-5100
www.fultonsheriff.net
CONSENT FOR CRIMINAL HISTORY RECORDS INQUIRY
I, _______________________________________, hereby authorize the Fulton County Sheriff’s
Office to receive any criminal history record information pertaining to me which may be in the
files of any state or local criminal justice agency in Georgia.
Signature: _______________________________ Date: __________________
Background Investigations
Criminal Investigation
