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Name-Based Criminal Background History Record Information Consent/Inquiry Form
I hereby authorize
Alto Police Department
to conduct an inquiry for
Agency/Company
Accurate Background
(company) with the purpose(s) listed below and receive any Georgia
and/or national criminal background history record information as authorized by state and federal law.
Full Name (print)
AKA name(s)
Address
Sex
Race
Date of Birth
This authorization is valid for
90
Social Security Number
days from date of signature.
I,
, give consent to the above-named
entity to perform periodic criminal history background checks for the duration of my employment.
Signature
Date
Purpose Code Used: (check one that apply)
E – Employment
N – Working with Elderly
W – Working with Children
Official use only:
Inquiry:
Time of Inquiry:
Operator’s Initials:
The inquiry resulted in the following: (check all that apply)
No Criminal Record Available
Criminal Record (Attached/Released)
No NCIC/GCIC Warrant
Possi