AUTHORITY FOR RELEASE OF INFORMATION State and Federal Record Check Home/Business Telephone Number ____________________________________ I authorize the North Carolina Department of Justice through the State Bureau of Investigation, Division of support Services to perform a fingerprint search of the State’s criminal history record file and a fingerprint search of the Federal Bureau of Investigation’s files for a notional criminal history record check in connection with my application for license with the ABC Commission/Alcohol Law Enforcement Division pursuant to N.C.G.S. 18b-902 (HB 1638). (Print or Type) Last Name First Middle Maiden ____________________ ________________ _______________ __________________ Social Security Number Date of Birth Sex Race ___________________ _______________ __________ _______________ I understand that the North Carolina State Bureau of Investigation, Division of Support Services, and its officials and employees shall not be held legally accountable in any way for providing this information to the Alcohol Law Enforcement Division and the ABC Commission, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the Alcohol Law Enforcement Division and ABC Commission cannot provide a hard copy of the results of this criminal history record check to me. Applicant/Employee Signature ________________________________________________ Date ________________________________ This request form must be accompanied with a transmittal letter from the Authorized Official or individual requesting Criminal History Record Information. This request must be mailed to: State Bureau of Investigation Attn: Identification Section/ Applicant Unit PO Box 29500 Raleigh, NC 27626-0500 ORI # ALEABC000 – ALCOHOL LAW ENFORCEMENT – ABC PERMITS 01-132-11 ALE/ABC Permits July 2006 SBI FINGERPRINT CARD CHECK - $14.00 _______ FBI FINGERPRINT CARD CHECK – 24.00 _______ American LegalNet, Inc. www.FormsWorkflow.com