Criminal Record Check Form

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SHP-158Q
01/15
MISSOURI STATE HIGHWAY PATROL
REQUEST FOR CRIMINAL RECORD CHECK
PLEASE PRINT OR TYPE.
GENERAL INFORMATION
APPLICANT'S LAST NAME
FIRST
MIDDLE
JR / SR
MAIDEN / ALIAS LAST NAME
MIDDLE
JR / SR
FIRST
RACE
SEX
DATE OF BIRTH (MM/DD/YYYY)
SOCIAL SECURITY NUMBER
MALE
BLACK
INDIAN
OTHER
FEMALE
WHITE
ASIAN
STATE
ZIP CODE
ADDRESS
STREET - P.O. BOX
CITY
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TYPE OF RECORD CHECK — PROCESSING FEE — METHOD OF PAYMENT
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(per Sections 43.527 and 43.530, RSMo.)
$20.00 FINGERPRINT SEARCH
$2.00 NOTARY LETTER
$12.00 NAME SEARCH
Open Records
Based on NAME, DATE OF BIRTH,
Open and Closed Records
AND SOCIAL SECURITY NUMBER.
Response will be returned with all open
records and records of conviction.
Fee is payable either by check or money order (NO CASH) to "State of Missouri, Criminal Record System Fund."
Either the Date of Birth OR Social Security Number MUST be provided for processing.
For faster processing criminal record checks are available online at:
Please forward the request and fee to:
Missouri State Highway Patrol
Criminal Justice Information Services Division
Post Office Box 9500
Jefferson City, MO 65102
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MSHP / CENTRAL REPOSITORY RESPONSE
SEND REPLY TO
(Print or type your mailing label below.)
Telephone (include area code)

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