Criminal History Request Form - York County Department Of Emergency Services
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1YORK COUNTY DEPARTMENT OF EMERGENCY SERVICES
**CRIMINAL HISTORY REQUEST FORM**
FIELDS MARKED WITH ASTERISKS (**) ARE MANDATORY AND WILL NOT BE PROCESSED IF NOT COMPLETE
**Name:______________________________________________________________________
**DOB:_____________ Race:__________ Sex:____________ SSN#:_____________________
OLN:__________________________________________ State:________________________
INFORMATION REQUESTED
MISSILE (York Co warrant)
YES ____ NO ____
CLEAN (PA only)
YES ____ NO ____
NCIC (Nationwide)
YES ____ NO ____
PSP MASTER NAME (PA Crim History) YES ____ NO ____
NCIC III (Nationwide Crim History)
YES ____ NO ____
OLN INFO (Driver’s License)
YES ____ NO ____
JNET PHOTO (PA Driver’s Photo)
YES ____ NO ____
CPIN PHOTO (PA Arrest Photo)
YES ____ NO ____
PFA
YES ____ NO ____
**Reason for Request: C – Criminal Justice Purposes J – Criminal Justice Employment Purposes
D – Domestic Violence Purposes F – Firearm Purposes
**Case #, Docket #, Citation #, Type of charge(s),etc__________________________________________
________URGENT
REASON FOR URGENCY____________________________
REQUESTING AGENCY INFORMATION
**Department:_________________________________________________________________________
**Individual Requesting:_________________________________________________________________
**ORI #: PA______________________ **Date:_____________________
**************************DO NOT WRITE BELOW THIS LINE*****************************
The following are the results of your Criminal History Request. Any of the fields checked “YES” will be
accompanied by a print out of the results. Any fields checked “NO” indicate that no record was found.
MISSILE
YES ____ NO ____
NCIC III
YES ____ NO ____
CLEAN
YES ____ NO ____
PA CRIM HISTORY YES ____ NO ____
NCIC
YES ____ NO ____
PFA
YES ____ NO ____
OLN
YES ____ NO ____
PHOTO
YES ____ NO ____
( JNET ____ CPIN____)
**DISPATCHER INITIALS ______________
**************************PRINT LEGIBLY OR TYPE ALL INFORMATION*****************************
When completed, fax this form to 717-840-7553. Info will either be faxed back to the requestor, mailed the
next business day or may be picked up by the requestor. Please indicate your preference.
MAIL _______ FAX _______ PICKUP _______
(Revised April 2007)
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