Request For Conviction Records/childe Care Form - Kentucky State Police
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REQUEST FOR CONVICTION RECORDS/ CHILD CARE
Pursuant to KRS 17.165, request is made for any record of conviction found in the files of the Kentucky centralized criminal
history record information system regarding the person identified herein. This information shall be released to:
________________________________________________________________________________________________
Agency Name and Address
ACKNOWLEDGMENT BY APPLICANT
I have applied for a position with the above stated agency. I am requesting that the Kentucky State Police provide the agency
with any record of conviction found in the files of the Kentucky centralized criminal history record information system. I know
that I have the right to inspect my criminal history record and to request correction of any inaccurate information. If I do not
exercise that right, I agree to hold harmless the Kentucky State police and any Kentucky State Police employee(s) from any claim
for damages arising from the dissemination of inaccurate information.
APPLICANT INFORMATION (PLEASE PRINT)
NAME: __________________ _____________________ ________________________ ___________________________
First
Middle
Last
Maiden
ADDRESS: ______________________________________ _______________________ ___________ ________________
Street
City
State
Zip
SEX:
RACE: _______ DATE OF BIRTH: _______________ SOC SEC NO: ______________________________
_______
__________________________________
____________________________________
Signature
Date
Witness
Date
INSTRUCTIONS:
Requesting agencies should ensure that all application information is completed.
Requesting agencies should forward a check or money order made payable to the Kentucky State Treasurer in the amount of
$20.00 for each submitted form. Requests should be accompanied by two, self –addressed stamped envelopes – one bearing the
name and address of the requesting agency and the other bearing the name and address of the applicant.
The Kentucky State Police will charge a $25.00 fee on each returned check.
RETURN THIS FORM TO:
Kentucky State Police
Criminal Identifications and Records Branch
Criminal Records Dissemination Section
1250 Louisville Road
Frankfort, KY 40601
Visit us online @
Revised 09/08
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