Form Sp 4-164 - Pennsylvania State Police Request For Criminal Record Check
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1PENNSYLVANIA STATE POLICE
SP 4-164 (7-2009)
REQUEST FOR CRIMINAL RECORD CHECK
This form is to be completed in ink by the requester – (information will be mailed to
FOR CENTRAL REPOSITORY USE ONLY
the requester only). If this form is not legible or not properly completed, it will be
CONTROL NUMBER
returned unprocessed to the requester. A response may take four weeks or longer.
Warning: A person commits a misdemeanor of the third degree if he/she makes a written false
statement, which he/she does not believe to be true.
AFTER COMPLETION MAIL TO:
TRY OUR WEBSITE FOR A QUICKER RESPONSE
PENNSYLVANIA STATE POLICE
https://epatch.state.pa.us
CENTRAL REPOSITORY – 164
1800 ELMERTON AVENUE
HARRISBURG, PA 17110-9758
NAME/
REQUESTER
Local Number 717-425-5546
WELSH MOUNTAIN HEALTH CENTERS
1-888-QUERYPA (1-888-783-7972)
DO NOT SEND CASH OR PERSONAL
ADDRESS
CHECK
584 SPRINGVILLE ROAD
CHECK ONE BLOCK
CITY/STATE/
INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE A
ZIP CODE
CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF
NEW HOLLAND, PA 17557
$10.00, PAYABLE TO:
“COMMONWEALTH OF PENNSYLVANIA”
THE FEE IS NONREFUNDABLE
FEE EXEMPT-NONCRIMINAL JUSTICE AGENCY – NO FEE
CONTACT TELEPHONE NUMBER (INCLUDING AREA CODE)
-
-
NAME/SUBJECT OF RECORD CHECK (FIRST)
(MIDDLE)
(LAST)
MAIDEN NAME AND/OR ALIASES
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SEX
RACE
(MM/DD/YYYY)
The Pennsylvania State Police response will be based on the comparison of the data provided by the requester
against the information contained in the files of the Pennsylvania State Police Central Repository only
REASON FOR REQUEST: All requests $10.00
***MAKE ALL MONEY ORDERS PAYABLE TO: COMMONWEALTH OF PENNSYLVANIA ***
◄◄◄◄◄◄CHECK BOX THAT MOST APPLIES TO THE PURPOSE OF THIS REQUEST►►►►►►
INTERNATIONAL ADOPTION -
INTERNATIONAL ADOPTION MUST BE NOTARIZED.
ADOPTION (DOMESTIC)
EMPLOYMENT/SCREENING
PASSPORT
ATTORNEY
FOSTER CARE
PRIVATE INVESTIGATIONS
BANKING
HEALTHCARE
SOCIAL SERVICES
BAR ASSOCIATION
HOUSING
TENANT CHECK
CHURCH
INSURANCE LICENSE
VISA
CHILD CARE
MENTAL HEALTH
VOLUNTEER AMBULANCE/FIREFIGHTER
EDUCATION
NURSE AID TRAINING
VOLUNTEER
ELDER CARE
OTHER
_________________
EMERGENCY MANAGEMENT
ACCESS & REVIEW -
(NOT FOR EMPLOYMENT PURPOSES. MUST BE MAILED INTO THE CENTRAL REPOSITORY.)
AVAILABLE ONLY TO SUBJECT OF RECORD OR LEGAL REPRESENTATIVE WITH LEGAL AFFIDAVIT ATTACHED
FOR THE PURPOSE OF REVIEWING YOUR CRIMINAL HISTORY.
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