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State of New Hampshire

Criminal Records Unit

Department of Safety

33 Hazen Drive, Concord, NH 03305

DIVISION OF STATE POLICE

CRIMINAL HISTORY RECORD INFORMATION RELEASE AUTHORIZATION FORM
INSTRUCTIONS
NH RSA 106-B:14 and Administrative Rule Saf-C 5700 authorizes the dissemination of NH Criminal History Record Information (CHRI) for noncriminal justice purposes. In NH, all CHRI is confidential and released only upon the knowledge and permission of the individual of whom the
request is made. Individuals requesting their own record in person need only to complete Section I. If the CHRI is to be released to a third
party, both Section I and Section II must be completed. All requests by mail must have both sections completed and Section II notarized.

SECTION I (PLEASE PRINT CLEARLY)

SECTION II

NAME
LAST

(MAIDEN/ALIAS)

FIRST

I hereby authorize the release of my criminal record
conviction(s), if any, to the following individual:

MI

_
ADDRESS ___________________________________
ST