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State of New Hampshire

Department of Safety

DIVISION OF STATE POLICE

Criminal Records Unit

33 Hazen Drive, Concord, NH 03305

NEW HAMPSHIRE CRIMINAL HISTORY RECORD INFORMATION AUTHORIZATION FORM

DRIVER EDUCATION INSTRUCTORS NH RSA 263:44-b II

INSTRUCTIONS

NH RSA 106-B:14 and Administrative Rule Saf-C 5700 authorizes the dissemination of NH Criminal History Record Information (CHRI) for non-

criminal justice purposes. In NH, all CHRI is confidential and released only upon the knowledge and permission of the individual of whom the

request is made. Individuals requesting their own record in person need only to complete Section I. If the CHRI is to be released to a third

party, both Section I and Section II must be completed. All requests by mail must have both sections completed and Section II notarized.

SECTION I

Last Name: ______________________________ First Name: ____________________________ MI: ___________

(Maiden/Alias)

Address: __________________________________City: ___________________State: ________ Zip: ___________

Date of Birth: _________________________ Hair Color: _____________________ Eye Color: _________________

Male:

Female:

Driver License #: ______________________________ State: _______

My signature below certifies I am the individual listed above and the information provided is true.

Signature: ________________________________________________ Date: ______________________

Signed under penalty of unsworn falsification pursuant to RSA 641:3

SECTION II

I hereby authorize the release of my criminal record convictions(s), if any, to the following individual:

The New Hampshire Division of Motor Vehicles - Driver Education Section

___________________________________________________________________________________

Name of Person/Entity to Receive Record

Address: ______________________________________City: ________________ State: ___________ Zip: _____

Your Signature: ___________________________________________________________ Date: ______________

Notary’s Signature: ________________________________________________________ Date: ______________

Signature of person/entity to receive Record ____________________________________ Date: ______________

RECORD CHALLENGE

Saf-C 5703.12 Procedure for Correcting a CHRI (a) Persons or their attorneys desiring access to their CHRI for the purpose of challenge or correction

shall appear at the central repository. (b) A copy shall be provided to a person if after review he/she indicates he/she needs the copy to pursue the

challenge. (c) Any person making a challenge shall identify that portion of his/her CHRI which he/she believes to be inaccurate or incorrect, and shall also

give a correct version of his/her record with an explanation of the reason that he/she believes his/her version to be correct. (d) The director shall take the

following actions within 30 days of receipt of challenge: (1) Review the records and contact the law enforcement agency or court which submitted the record

to compare the information to determine whether the challenge is valid; (2) If the challenge is valid, which means there is a discrepancy between the

information submitted and the information maintained by the law enforcement agency or court, the record shall be corrected and the person and appropriate

CJAs shall be notified; and (3) If the challenge is invalid, the person shall be informed and advised of the right to appeal pursuant to RSA 541. (e) When a

record has been corrected, the division shall notify all non-criminal justice agencies, to whom the data has been disseminated in the last year, of the

correction.(f) The person shall be entitled to review the information that records the facts, dates, and results of each formal stage of the criminal justice

process through which he passes, to ensure that all such steps are completely and accurately recorded.

WARNING: The Division of State Police is the Criminal Record Repository for the State of New Hampshire. The record you have received is based only on

what has been reported to the Repository and may not be a complete Criminal History Record of the named individual.

FEES:

LIVESCAN - $41.50 ($51.50 if printed at a state police livescan site)

INKED - $51.50

Make checks payable to:

State of NH – Criminal Records

Applicant fingerprint card must be submitted at the same time as payment and this form

DSSP380 (02/14)

Form Dssp380 - New Hampshire Criminal History Record Information Authorization Form - Driver Education Instructions - State Of New Hampshire

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