Instructions for Application for Criminal History Record Enclosed is an a pplication for Criminal History Record from the State of Utah , Department of Public Safety, Bureau of Criminal Identification . Please complete all of the steps described below. Failure to properly complete one of the steps may cause a delay in processing your application. 1. Fill out the top portion of the application. List all of your previous names including married and ma iden names. Be sure to read and sign the application. 2. Take the application to a law enforcement agency such as your city police department or county Make sure the law enforcement official who takes your fingerprints fills out the portion of the Valid g overnment - issued photo ID must be provided to the official taking your prints (for example, passport, sta te ID card, consulate ID card, and driver license.) ing ID. Driving Privilege Cards state on them that they are not to be used as ID. NOTE: The fingerprints may be taken at our office, Bur eau of Criminal Identification, 3888 West 5400 South, Taylorsville, Utah. 3. The application fee is $15.00. Select a method of payment by making a check mark in the appropriate box . Checks and money orders must be US Currency and be , MasterCard , Discover Card or AMEX ) , please fill out the requested information on the application. Credit card numbers must include: the signature of the cardholder, the three - digit control number located on the back of the card, the expiration date, and the zip code of card billing address; sorry we cannot accept credit cards outside of the US . Cash is accepted only when applying in person. DO NOT SEND CASH IN THE M AIL. 4 . Your report will be mailed to the mailing address indicate d on the application form. If the information needs to be sent to a third party, the third party release form must be filled out and submitted along with your application. 5. Mail the application, fee and release form (if applicable) to: UTAH BUREAU OF CRIMINAL IDENTIFICATION 3888 West 5400 South Taylorsville, Utah 84129 The re port can not be faxed or sent by e - mail. If you have questions you may call (801) 965 - 4445 from 8 :00 AM - 5 :00 PM Monday - Friday . Our office is closed weekends and holidays . You may also v isit our website at http://publicsafety .utah.gov/bci/ The Bureau of Criminal Identification does not maintain juvenile offender records . Requests for such records must be made directly to the Juvenile Court . American LegalNet, Inc. www.FormsWorkFlow.com METHOD OF PAYMENT (Only to be filled out if application is mailed in. Che ck appropriate box for payment) Check, Money BCI There will be a $20.00 service charge for any returned check. Credit Card (cannot use foreign credit cards) must be Visa Master Card Discover AMEX Fill out the info rmation below to pay by credit card. *3 or 4 digit control # Exp Date MM/YY Cardholder signature: Zip Code Associated with Credit Card: R form 98 - 1 - 03, Rev 4/2019 APPLICATION FOR CRIMINAL HISTORY RECORD Identification 3888 West 5400 South, Taylorsville, Utah 84129 - Telephone: (801)965 - 4445 WHEN FILLING OUT THIS APPLICATION TYPE OR PRINT IN BLACK INK. Your application will not be processed unless all sections of this form are filled out completely. You will need a valid form of government issued picture ID and $15.00 fee. NAME : DATE OF BIRTH ( Last Name ) ( First Name ) ( Middle Name ) PREVIOUSLY USED NAME(S) (Maiden, etc.): MAILING ADDRESS : ( Street/Box number ) ( City ) ( State ) ( Zip ) PHYSICAL ADDRESS : ( Street ) ( City ) ( State ) ( Zip ) HOME PHONE NUMBER : DAYTIME PHONE NUMBER : SOCIAL SECURITY : DRIVER LICENSE # AND STATE : PHYSICAL DESCRIPTION : HGT/ WGT/ EYE COLOR/ SEX/ RACE/ I hereby declare that I am the person listed above and am entitled to my criminal record as provided by Utah Code Ann. 247 53 - 10 - 108( 9 )(a). The information contained in this written statement is true and correct to the best of my knowledge and I understand that any false s tatements I make that I do not believe to be true may subject me to criminal punishment as a class B misdemeanor pursuant to Utah Code Ann. 24776 - 8 - 504. Signature of applicant : Date : FINGERPRINT INSTRUCTIONS: (OFFICIAL TAKING PRINTS) Confirm identity of applicant with identification that shows photo, signature and date of birth. Confirm ID with the information above, then list the type of government issued ID used and the ID number in the space provided below. Fingerpr This Area must be completed by OFFICIAL TAKING PRINTS Type of identification used: (Utah Driving Privilege Cards are not valid ID and will not be accepted) Identification number: Name on ID: Fingerprints taken by: ( PRINT NAME ) Agency Name: Badge # Date Printed: ( If applicable ) FINGERPRINTS BUREAU USE ONLY AFIS Confirmation SID# R&F American LegalNet, Inc. www.FormsWorkFlow.com