Personal Criminal Record Request Form North Andover printable pdf download

NORTH ANDOVER POLICE DEPARTMENT

1475 Osgood Street

North Andover, Massachusetts 01832

978-683-31689

The Commonwealth of Massachusetts

Executive Office of Public Safety

Criminal History Systems Board

Criminal Justice Information System

200 Arlington Street Suite 2200

Chelsea, Massachusetts 02150

Phone: (617) 660-4600

Personal Criminal Record Request Form

If you want a copy of your own record, use this form and return it to the address above with a self-

addressed, stamped envelope. You will receive a response by mail. YOU MUST HAVE YOUR

SIGNATURE NOTARIZED BY A NOTARY PUBLIC BEFORE YOUR REQUEST CAN BE

PROCESSED. No walk-in service is available. (PLEASE PRINT)

** Please check here if you need this for immigration/adoption purposes [ ]

Name:

__________________________________________________________

Maiden Name/Alias:

__________________________________________________________

Date of Birth:

______________________________________________ (mm/dd/yyyy)

Social Security Number: __________________________________________________________

Address:

__________________________________________________________

Town/State/Zip Code:

__________________________________________________________

Mother’s Maiden Name: __________________________________________________________

I swear that I am the above-name person under the pains a penalties of perjury, and further

acknowledge that I am aware that Massachusetts law prohibits a person from requesting or

requiring me to produce a copy of my own record, unless so authorized by the Criminal History

Systems Board.

Signature of Applicant: ___________________________________ Date: _________________

AUTHENTICATION OF SIGNATURE BY NOTARY PUBLIC

___________________, ss.

County

Then appeared before me the above-named, ______________________________ and swore

the statements made herein to be true.

Dated: ________________

Notary Public: ________________________________________

My Commission Expires: _________________________________________________________

Personal Criminal Record Request Form North Andover