THIRD PARTY RELEASE FORM Utah Department of Public Safety � Bureau of Criminal Identification 3888 West 5400 South, Taylorsville, Utah 84129 WHEN FILLING OUT THIS FORM, TYPE OR PRINT IN BLACK INK. If you wish to have your criminal history record or certificate of eligibility sent to an individual other than yourself, you must indicate the name of the person or agency to whom you would like the document sent and the mailing address. NAME: (Name of Person to Receive Report) AGENCY: _____________________________________________________________________ (if applicable) MAILING ADDRESS: (Street/Box number) (City) (State) (Zip) I request that the criminal history record or certificate of eligibility for which I applied be released to the individual or agency indicated above at the listed address. I hereby release the Bureau of Criminal Identification from any liability resulting from such release. Name of applicant (Print): Signature of applicant: Date: _______________________ American LegalNet, Inc. www.FormsWorkFlow.com