Form Chrd01 - Criminal History Information Request
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1CRIMINAL HISTORY INFORMATION REQUEST
Oklahoma State Bureau of Investigation
Date
Criminal History Reporting Unit
6600
North Harvey Oklahoma City, OK
73116
(405) 848-6724
PURSUANT TO PROVISIONS OF TITLE 5 1. OKLAHOMA STATUTES 1981, SECTION 24A.1 et seq. AND PROCEDURES OUTLINED
BY
THE
OKLAHOMA STATE BUREAU OF INVESTIGATION, I REQUEST
A
CRIMINAL HISTORY INFORMATION CHECK OF YOUR
NAME
FILES ON THE
FOLLOWING SUBJECT (S). THE PROCESSING FEE OF FIFTEEN DOLLARS ($15.00) PER SUBJECT FOR A
SEARCH OR NINETEEN
IN-STATE FINGERPRINT SEARCH
DOLLARS ($19.00) PER SUBJECT FOR AN
IS HEREBY TENDERED
Form of Payment:
Cash
Business Check
Money Order
Cashier's Check
Visa
MasterCard
Discover
Account Number
Cardholder's Signature
Expiration Date
(Requests with
signature will
no
be
returned
unprocessed.)
NAME OF INDIVIDUAL, BUSINESS,
OR AGENCY MAKJNG REQUEST
If paying with cash, money order. cashier's check or credit card, this information will be
YOUR NAME AND ADDRESS.
INDIVIDUAL. BUSINESS,
AGENCY ADDRESS
OR
Street Address or Post Office Box
PHONE
NUMBER:
/
/
ZIP
City
State
Purpose of Request
(PLEASE CHECK, ONLY IF APPLICABLE)
This request is being made in compliance with the provisions of the Oklahoma Child Care Facilities Licensing act ,10 0, 1991,
Sections 401 through 410; a search of the Oklahoma Department of Corrections Sex Offenders Registration List, 57 0. 1991,
Section 581 et seq., is required:__________ . The sex offender search must be requested at the time the original criminal history
record check is submitted; amended replies to include this information will not be furnished free of charge at a later date.
FOR OSBl USE ONLY-DO NOT WRITE
MIS SPACE.
IN
Signature of Requestor
SUBJECT TO BE SEARCHED:
(All request forms must be typed or the information legibly printed in ink by the requestor; forms completed in pencil are
unacceptable. Handwritten requests which are not easily read will be retuned unprocessed.)
NAME
(Last
First
Middle)
Alias Names
(include maiden name, all married
and any other names used)
names,
RACE
SEX
FOR OSBI USE ONLY – DO NOT WRITE IN THIS SPACE
DATE OF BIRTH
OR AGE (mandatory)
( I f an age is provided. it must be specific: an age range
not acceptable and will be returned unprocessed.
is
Additionally. customers who submit common names with an age may be required to provide
full
date of birth
before the request can be processed. See Title
5
section 24A.5
the Oklahoma Open Records Act.)
1
( 2 )
of
SOCIAL SECURITY NUMBER
All criminal history record information provided in compliance with 51 O.S. 1981, Section 24A.l et seq., is based upon
Fingerprints taken by the contributing law enforcement or criminal justice agency at the time of arrest and/or
incarceration.
(Form #CHRD01)
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