Criminal Record Release Authorization Form - New Hampshire Department Of Safety, Form Dsmv 505 - Release Of Motor Vehicle Records

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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_________________
PURPOSE FOR RECORD:
Housing
Employment
Annulment/Expungement
Other______________
Specify
My below signature certifies that 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______________
(AffixSeal)
(Comm Exp.)
________________________________________________________DATE_________________
SIGNATURE OF PERSON / FIRM TO RECEIVE RECORD
NOTE:
A $15.00 fee is required for each request - make checks payable to: State of NH – Criminal
Records

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