BCI&I RELEASE AUTHORIZATION I hereby certify that I have given the Ohio Attorney General permission to obtain a copy of any arrest or conviction record pertaining to me now available to the Ohio Bureau of Criminal Identification and Investigation (BCI&I), London, Ohio. I hereby release BCI&I and all individuals connected therewith from all liability in connection with the dissemination of such arrest and conviction data. _______________________________________ Name of Facility being Investigated _______________________________________ Name _______________________________________ Social Security Number _______________________________________ Date of Birth _______________________________________ Home Address (Number and Street) _______________________________________ City, State and Zip Code _______________________________________ County of Residence _______________________________________ Signature ____________________________ Date Sworn to and subscribed before me this _____ day of ____________________________, 200__. __________________________________________ NOTARY PUBLIC My Commission Expires:_____________________ Under Ohio Revised Code 2921.11 and 2929.11, perjury is a felony of the third degree; punishable by imprisonment for one to ten years and a fine up to $5,000. Under Ohio Revised Code 2921.13 and 2929.21, falsification is a misdemeanor of the first degree; punishable by imprisonment for six months and a fine up to $1,000. American LegalNet, Inc. www.FormsWorkflow.com