Criminal Record Release Authorization Form
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1New Hampshire Department of Safety
DIVISION OF STATE POLICE
Central Repository for Criminal Records
33 Hazen Drive, Concord, NH 03305
CRIMINAL RECORD RELEASE AUTHORIZATION FORM
SECTION I
PLEASE TYPE OR PRINT CLEARLY, ALL INFORMATION IN THIS SECTION MUST BE COMPLETED
NAME____________________________________________________________________________
LAST
(MAIDEN/ALIAS)
FIRST
MI
ADDRESS________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
DATE OF BIRTH__________________ HAIR COLOR________ EYE COLOR_______ SEX_______
DRIVER LICENSE NUMBER_________________________STATE_____________
PURPOSE FOR RECORD:
Housing
Employment
Annulment/Expungement
Other __________
My below signature certifies I am the individual listed above and that the information provided is true.
YOUR SIGNATURE:________________________________________ DATE___________
Signed under penalty of unsworn falsification pursuant to NH RSA 641:3
SECTION II
IF RECORD IS TO BE MAILED TO YOU, OR RECEIVED BY SOMEONE OTHER THAN YOURSELF,
ALL OF SECTION II MUST BE COMPLETED
I hereby authorize the release of my criminal record conviction(s), if any, to the following individual:
NAME OF PERSON / FIRM TO RECEIVE RECORD
ADDRESS
STREET
CITY
STATE
ZIP CODE
YOUR SIGNATURE________________________________________ DATE____________
NOTARY’S SIGNATURE____________________________________ DATE____________
(Affix Seal)
(Comm. Exp.)
_________________________________________________________ DATE___________
SIGNATURE OF PERSON / FIRM TO RECEIVE RECORD
NOTE: A $25.00 fee is required for each request- make checks payable to: State of NH –
Criminal Records.
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