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 __________ My below signature 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 NH 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. American LegalNet, Inc. www.FormsWorkFlow.com