Criminal History Consent Form REQUEST TO RESTRICT ARREST RECORD Prior to 07/01/2013 One(1) Date of Arrest per Request First Name * Middle Name Last Name * Address * Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Sex * Male Female Race * American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Date of Birth * Social Security Number * Phone * Email * Arresting Agency * Date of Arrest * Offense(s) Arrested For * 0 of 400 max characters * I request the arrest record information (Date of Arrest and associated charges) described above pertaining to me be restricted from the record(s) of the arresting agency pursuant to the provisions of O.C.G.A. §35-3-37. Signature * signature keyboard Clear Date * Name-Based Criminal History Record Information Consent/Inquiry * I hereby authorize the Clayton County Sheriff's Office to conduct an inquiry for the purpose listed above and receive any Georgia and/or national criminal history record information as authorized by state and federal law. * This authorization is valid for 30 days from date of signature. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
