Fillable Name-Based Criminal History Record Information Consent/Inquiry Form the (Columbus Consolidated Government)

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Name-Based Criminal History Record Information Consent/Inquiry Form the (Columbus Consolidated Government)

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The Name-Based Criminal History Record Information Consent/Inquiry Form the (Columbus Consolidated Government) form is 1 page long and contains:

  • 2 signatures
  • 14 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Columbus Consolidated Government

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Revised June 2017
Name-Based Criminal History Record Information Consent/Inquiry Form
I hereby authorize _________________________________________________ to conduct an inquiry for
Agency/Company
the purpose(s) listed below and receive any Georgia and/or national criminal history record information
as authorized by state and federal law.
Full Name (print)
Address
Sex
Race
Date of Birth
Social Security Number
This authorization is valid for __________________ days from date of signature.
I, _________________________________________________ , give consent to the above-named
entity to perform periodic criminal history background checks for the duration of my employment.
______________________________________________________________ __________________
Signature Date
_________________________________________ ________________ __________________
Attorney for Individual (Pur E and U Only) Bar Number Date
Date of Inquiry: _____________ Time of Inquiry: _____________ Operator’s Initials: ______________
Purpose Code Used: (check all that apply)
E - Employment
J - Civilian Criminal Justice Employment (State & III Info Received)
M - Working with Mentally Disabled/Developmentally Disabled
N - Working with Elderly
P - Public Records
U - Personal Copy
W - Working with Children
Z - Sworn Criminal Justice Employment (State & III Info Received)
The inquiry resulted in the following: (check all that apply)
No Criminal Record Available
Criminal Record (Attached/Released)
No NCIC/GCIC Warrant
Possible NCIC/GCIC Warrant (List Wanting Agency Below)
Wanting Agency Name: __________________________________________________________
Wanting Agency Telephone: ______________________________________________________
________________________________________________________________ ___________________
Agency Designee Signature and Title Date
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Name-Based Criminal History Record Information ConsentInquiry Form the (Columbus Consolidated Government)

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Completed 2 August 2020

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