Form Dssp256 - Criminal Record Release Authorization Form - New Hampshire Department Of Safety

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State of New 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 ________________
Housing
Employment
Annulment/Expungement
Other: _______________
PURPOSE OF RECORD:
My signature below 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 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
DSSP256 (Rev. 05/12)

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