Criminal Record Release Authorization Form

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 ________________ PURPOSE OF RECORD: Housing Employment Annulment/Expungement Other: _______________ 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) American LegalNet, Inc. www.FormsWorkFlow.com