Asp-122 - Individual Record Check Form (Page 2 of 2) in pdf

Asp-122 - Individual Record Check Form Page 2

ARKANSAS STATE POLICE

ASP-122

(Rev. 04/00)

Identification Bureau

Individual Record Check Form

VOLUNTEER

Full Name: ________________________________________________________/__________________

Last Name

Middle

First

Maiden/Other

Date of Birth: ____________________________ State of Birth: ___________Race: ____Sex: ____

(Month/Day/Year)

Social Security #: ________________________________ Driver’s License #: __________________

State

Mailing Address: ______________________________________________________________________

Street

City

State

ZIP

Daytime Phone #: (_____)____________________________

I GIVE MY CONSENT FOR THE ARKANSAS STATE POLICE TO CONDUCT A CRIMINAL

RECORD SEARCH ON MYSELF AND RELEASE ANY RESULTS TO THE FOLLOWING

PERSON OR ENTITY:

Name of entity:________________________________________________________________________

address: _____________________________________________________________________________

Signature: ______________________________________________________ Date: _______________

(First/MI/Last Name)

(Month/Day/Year)

(NO REQUEST WILL BE PROCESSED WITHOUT A NOTARIZED SIGNATURE)

STATE OF _____________________________________

COUNTY OF ____________________________________

Subscribed and sworn before me, a Notary Public, in and for the county and state

aforesaid, this the ______________ day of ____________________, 20 ________________ .

_________________________________

Notary Public

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82001 Civil Record Check

80001 FBI Record Check

Asp-122 - Individual Record Check Form Page 2