Request For Access To Information Form - Scotland Police Page 3

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RESTRICTED – WHEN COMPLETE
CONTACT DETAILS
(A telephone number and/or e-mail address must be provided in case we
need to contact you about your request)
Telephone Number
E-Mail Address
INFORMATION REQUESTED.
(Tick all that apply).
If “Other” identify data requested
Scottish Criminal History System – Conviction History
Yes
No
Police National Computer – Conviction History
Yes
No
If you require information held by Police Service of Scotland other than conviction data,
please provide details below.
Were you (tick appropriate boxes)
A person reporting an offence or incident
A witness to an offence or incident
A victim of an offence
Other (please explain below)
Date, time and place of offence/incident
Details of offence/incident
Any other information to assist us to identify the information you require
DECLARATION (to be signed by the applicant)
The information which I have supplied in this application is correct and I am the person to whom
it relates.
Signature:
Date:
RESTRICTED – WHEN COMPLETE
052-002
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