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706-778-8585

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181 Larkin Street, Cornelia, GA 30531
(706) 778-8585

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Home » Consent Form

Consent Form - Revised March 2019

Name-Based Criminal History Record Information Consent/Inquiry Form

I hereby authorize Agency/Company to conduct an inquiry for

Agency/Company *

The purpose listed below and receive any Georgia and/or national criminal history record information as authorized by state and federal law.

Full Name *

Email *

Address *

Sex *

Race *

Attorney Wanting and

Date Of Birth *

Social Security Number *

This authorization is valid for 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 *

Attorney for Individual (Pur E and U Only) *

Bar Number *

Date *

Purpose Code Used: (check one) *

E - Employment
M - Working with Mentally Disabled
N - Working with Elderly
W - Working with Children
P - Public Records (no consent required)
U - Personal Copy
J - Civilian Criminal Justice Employment (State & III Info Received)
Z - Sworn Criminal Justice Employment (State & III Info Received)

NON-CRIMINAL JUSTICE PURPOSES, PERSONAL REQUEST (INDIVIDUAL OR THEIR ATTORNEY), CRIMINAL JUSTICE EMPLOYMENT

The inquiry resulted in the following: (check all that apply) *

No Criminal Record Available
Criminal Record (Attached/Released)
No NCIC/GCIC Warrant
Possible NCIC/GCIC Warrant (List Wanting Agency Below)

Wanting Agency Name *

Wanting Agency Telephone *

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181 Larkin Street
P.O. Box 785
Cornelia, GA 30531

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