DIVISION OF COMMERCIAL LICENSING AND REGULATION LIQUOR SECTION 233 Richmond Street, Suite 230 Providence, Rhode Island 02903-4230 Telephone (401) 222-2563 Facsimile (401) 222-6654 www.dbr.state.ri.us WAIVER (AUTHORIZATION FOR CRIMINAL BACKGROUND CHECK) I, _____________________________________________________________________________________________, (Applicant’s Full Name) of ____________________________________________________________________________________________ (Complete Address) have the date of birth of ____________________and Social Security number of ______________________________ am applying for a __________________________license with the Department of Business Regulation and I hereby direct and authorize the Bureau of Criminal Identification of the Department of Attorney General for the State of Rhode Island to make available to the Department of Business Regulation any criminal record or other disposition that the Bureau of Criminal Identification has on file in reference to me. I hereby waive and release any and all manner of actions, cause of actions, and demands of every kind, nature and description, arising from any release of criminal records and requests therefrom, whatsoever against the State of Rhode Island, Bureau of Criminal Identification, the Attorney General, employees of the Attorney General’s Office and officials of the Department of Business Regulation in both law and equity which I may now have or in the future may have. ___________________________________________ (Signature of Applicant) Notary Public: Sworn to before me on this _________________day of _________________________________20______ ___________________________________________My Commission Expires:______________________ (Notary Public) F9-8/04 American LegalNet, Inc. www.FormsWorkflow.com