Certified Record Check Request Form
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1Kansas Central Repository
Certified Record Check Request Form
Regular name-based record checks are to be requested on-line at
To:
Kansas Bureau of Investigation
From:
(Requestor's Full Name or Organization) (Please Print)
Attn: Central Repository
1620 SW Tyler
(Requestor's Point of Contact and title)
Topeka, KS 66612-1837
(Requestor's Mailing Address)
(City, State or Country and Zip)
(Requestor's Phone Number)
A criminal history record check of the Kansas Central Repository is requested for the following individual. The Full Name and Date
1.
of Birth are mandatory:
Full Name:
(Last Name)
(First Name)
(Middle Name)
Maiden or
Alias Name:
(Last Name)
(First Name)
(Middle Name)
Date of Birth:
Social Security Number:
Sex:
Race:
Place of Birth:
2. A fingerprint card [ is ] [ is not ] included.
3. Purpose for the criminal history record check (Please be specific):
4. Mailing address for the results of the record check, if different from the "From" address, above:
[
] Same as the "From" address above.
5. Enclosed is payment made payable to the KBI Record Check Fee Fund for the record check in the sum of:
[
] $30.00 for a certifed name-based check
[
] $45.00 for a certified Kansas fingerprint-based check
[
] $58.00 for a certified Kansas/national fingerprint-based check*
* A state or federal statute allowing a national search is required
Dissemination of criminal history information is governed by statutes, laws and regulations. The Requestor will comply with and be
6.
subject to the provisions of both State and Federal law regulations, including, but not limited to Title 28 (Judicial Administration) of
the Code of Federal Regulations and Kansas Statutues Annotated 22-4107 et seq.
Requestor agrees to limit disclosure of the information received to personnel who have a clear, distinct "need to know," and ensure that
7.
the information is used only for the purpose for which provided. Further, Requestor shall:
a.
Implement reasonable procedures to insure the confidentiality and security of any information received.
b.
Indemnify and hold harmless the KBI, their employees, including their heirs, executors, administrators, personal
representatives, successors, and assigns, from and against any and all causes of actions, claims, demands, suits, rights
and other proceedings of any nature which seek damages or ther remedies arising from the providing of criminal
history information.
The KBI has the right to demand return of all information provided to the Requestor when any rule, policy, procedure, regulation or
8.
law described in this request is violated or appears to be violated or for non-payment of any service.
I have read and understand my responsiblities when receiving record check information from the Kansas Central Repository, and I
9.
agree to safeguard and properly use all information I receive.
(Signature of Requestor)
Revised 06/2015
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