Notary Public Application / Criminal Record Release Authorization Form (Page 2 of 2) in pdf

Notary Public Application / Criminal Record Release Authorization Form Page 2

The State of New Hampshire

Department of State

CRIMINAL RECORD RELEASE AUTHORIZATION FORM

SECTION I

PLEASE TYPE OR PRINT CLEARLY

Name: __________________________________________________________________________

Last

(Maiden)

First

Middle

Address: ________________________________________________________________________

Street

City

State

Zip Code

Date of Birth: ___________________

Hair Color: _______________ Eye Color: ____________

Driver License Number: _______________________________________ State: ________________

By signing below you are certifying that you are the individual listed above and that the information provided is true under

penalty of forgery and unsworn falsification.

Signature ______________________________________________________

Date: _______________________

SECTION II

AUTHORIZATION TO RELEASE CRIMINAL CONVICTION RECORD INFORMATION

I hereby authorize the release of my criminal conviction record information to:

New Hampshire Secretary of State

107 North Main Street, Room 204

Concord, NH 03301

Applicant’s Signature: ___________________________________________________________________________

Signed before me this __________ day of _____________________________, 20 __

seal

______________________________________________

________________________________

Notary Public/Justice of the Peace

(Commission expiration date)

Recipient’s Signature: ______________________________________________________________________

Deputy Secretary of State

Notary Public Application / Criminal Record Release Authorization Form Page 2