New Hampshire Department of Safety
DIVISION OF STATE POLICE
Central Repository for Criminal Records
10 Hazen Drive
Concord, NH 03305

CRIMINAL RECORD RELEASE AUTHORIZATION FORM
PLEASE TYPE OF PRINT CLEARLY
SECTION I
Name: ________________________________________________________________________
         Last           (Maiden)             First                       Mi.

Address: ______________________________________________________________________
           Street               City                    State           Zip

Date of Birth: ______________ Hair Color: _______________ Eye Color: _________________

Driver License Number: _______________________________ State: _____________________
By signing below you are certifying that you are the individual listed above and that the information provided is true under penalty of forgery and unsworn falsification. 
Releasee's Signature: __________________________________ Date: ____________________
SECTION II
AUTHORIZATION TO RELEASE CRIMINAL CONVICTION RECORD INFORMATION

I hereby authorize the release of my criminal conviction(s), if any, to the following individual:


Name: ________________________________________________________________________

Address: ______________________________________________________________________
           Street               City                    State           Zip

	Applicant's Signature: _______________________________________ Date: _________

	
	Notary's Signature: _________________________________________ Date: _________
                                (Affix Seal)                                (Comm. Exp.)


	Requestor's Signature: _______________________________________ Date: ________








Informus Form-CRNH