Third Party Release Form - Utah
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1THIRD PARTY RELEASE FORM
Utah Department of Public Safety • Bureau of Criminal Identification
3888 West 5400 South, Taylorsville, Utah 84129
WHEN FILLING OUT THIS FORM, TYPE OR PRINT IN BLACK INK. If you wish to have your criminal history record or certificate of
eligibility sent to an individual other than yourself, you must indicate the name of the person or agency to whom you would like the document sent and
the mailing address.
NAME:
(Name of Person to Receive Report)
AGENCY: _____________________________________________________________________ (if applicable)
MAILING ADDRESS:
(Street/Box number)
(City)
(State)
(Zip)
I request that the criminal history record or certificate of eligibility for which I applied be released to the individual or agency indicated
above at the listed address. I hereby release the Bureau of Criminal Identification from any liability resulting from such release.
Name of applicant (Print):
Signature of applicant:
Date: _______________________
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