Criminal History Report Form
Provide the information needed to prepare a criminal history report request. Use the same title everywhere in the form.
Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Criminal History Details
Case or Incident Reference Number
Jurisdiction / Location of Record
*
Date of Incident or Arrest
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Offense or Matter
*
Report Request and Delivery
Reason for Request
*
Employment
Volunteer Service
Tenant Screening
Personal Records Review
Licensing/Certification
Immigration/Travel
Legal Proceedings
Other
Preferred Delivery Method
*
Email
Postal Mail
In-Person Pickup
Secure Online Access
Additional Notes or Special Instructions
Submit Form
Should be Empty: