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Washington, D.C.

CRIMINAL HISTORY REQUEST

REQUEST RECORD OF: (Last Name, First, Middle)

TYPE OF REQUEST (CHECK ONE)

Law Enforcement Purpose

ADDRESS

Visas *

Employment */Licensing *

SEX

RACE

DATE OF BIRTH

PLACE OF BIRTH

Challenge *

NAME AND ADDRESS OF REQUESTING AGENCY

CALL BACK NUMBER

SIGNATURE OF AGENCY

BADGE NUMBER

DATE OF REQUEST

REQUEST MADE BY: (CHECK ONE)

IDENTIFICATION AND RECORDS DIVISION USE ONLY - Check if applicable

Mail

In Person

SUBJECT UNDER ARREST

CORRECT COLOR CODE

NLET

Telephone

REQUEST RECEIVED BY

DATE AND TIME RECEIVED

DATE AND TIME RETURNED

D.C. CODE 6-2276 IS QUOTED HERE FOR YOUR INFORMATION

It shall be an unlawful practice, punishable by a fine of not ore than three hundred dollars ($300.00) or imprisonment for not more than ten (10) days, or both,

for any person to require the production of an arrest record or any copy, extract, or statement thereof, at the monetary expense of any individual to whom such

record may relate. Such “arrest records” shall contain only listings of convictions and forfeitures of collateral that have occurred within ten (10) years of the

time at which such record is requested.

(Dec. 13, 1977, D.C. Law 2-38, title II, 266, 24 DCR 6038.)

* I hereby authorize the release of my adult arrest record revealing convictions and forfeitures within the past ten (10) years.

Signature

Date

RESULTS OF CRIMINAL HISTORY FILE SEARCH

Name Search

Fingerprint Search

TO:

Criminal History Users

This request concerns information whose collection, dissemination, and use are conditioned and restricted by applicable federal and

District of Columbia statutes, and policy of the Metropolitan Police Department. Continued assistance from this department is

conditioned upon your strict adherence to these regulations.

WARNING TO APPLYING AGENCIES: The Metropolitan Police Department does not guarantee either the accuracy of the record or that the

individual whose record is furnished is actually the same individual whose record was requested. To obtain accuracy, the record of the Court involved

should be examined. Positive identification can only be determined by comparable fingerprints. Records of arrests obtained from the Metropolitan

Police Department as detailed on this form are for convictions and forfeitures for the past 10 years prior to the date of request of this record exclusive

of periods of imprisonment, if any. This record does not reflect any cases which may be currently pending before the Courts, or cases where convictions

have been set aside pending appeals.

CHIEF OF POLICE

Date of Arrest

Charge(s)

Disposition

DOCUMENTS RELEASED

CRIMINAL HISTORY RECORD

PHOTOGRAPH

OTHER __________________________________________________________________________

PROSECUTION REPORT

FINGERPRINTS

OTHER _________________________________________________________________________