Agency Name, Street Address, City, State & Zip and Phone Number
INFORMED CONSENT
RELEASE OF PREDATORY OFFENDER
REGISTRATION and CRIMINAL HISTORY DATA
–
P
LEASE PRINT LEGIBLY
U
,
SE COMPLETE NAME
INCLUDING MIDDLE NAME
Last Name: ___________________ First Name: ____________ Middle Name: _______________
Maiden or Former Name (s):___________________________________________________
Date of Birth: _________________ Sex (M or F):________________
Social Security Number (optional): _____________________________
Driver’s License Number: _______________________________ Issuing State: ______________
Current Address:________________________________________________________________
City, State, Zip Code: ____________________________________________________________
I hereby authorize and grant my informed consent to the Minnesota Bureau of Criminal Apprehension to
release to <Name of Agency> any information contained about me in the Minnesota Computerized
Criminal History pursuant to Minnesota State Statue 299F.035 for the purpose of (volunteering,
employment, etc.) with this agency.
I hereby release the Minnesota Bureau of Criminal Apprehension and the <Name of Agency> from any and
all actions and causes of action, of any kind and nature whatsoever, past, present and future, arising out of the
release of information obtained with this consent.
This authorization shall be valid for a period of twelve (12) months from the date of signature.
Signature: __________________________________ Date: _____________________________
I hereby authorize and grant my informed consent to the Minnesota Bureau of Criminal Apprehension to
release to <Name of Agency> any information contained about me in the Minnesota Predatory Offender
Registry, including, but not limited to, information related to offenses which may have occurred when I was
a juvenile pursuant to Minnesota State Statute 299f.035 for the purpose of (volunteering, employment, etc.)
with this agency.
I hereby release the Minnesota Bureau of Criminal Apprehension and the <Name of Agency> from any and
all actions and causes of action, of any kind and nature whatsoever, past, present and future, arising out of the
release of information obtained with this consent.
This authorization shall be valid for a period of twelve (12) months from the date of signature.
Signature: __________________________________ Date: _____________________________
Updated on 4/28/2014