Hamilton County Sheriff Office Personal Information Release Form

Hamilton County Sheriff Office
Personal Information Release Form

First Name

Last Name

Address

Date of Birth

Social Security Number

Sex

Race

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I authorize the Hamilton County Sheriff Office to release information regarding any traffic or criminal convictions that I have on file. If it is necessary to verify this Authorization, I can be contact at the telephone number listed above. This authorization is void if not exercised by the person or organization listed on this form within one year from the date signed. I hereby agree to indemnify the County of Hamilton and the Hamilton County Sheriff and his representatives for any liability arising out of the improper use of the information provided.

CERTIFICATION OF PURPOSE

I, the undersigned, certify that the information applied for will be used only for the purpose for which it is requested and agree that this information will immediately be destroyed after use or if retained, not released outside my agency.

Type of Record Check: Criminal and Traffic

FOR SHERIFF OFFICE USE ONLY

Operator:

Date:

Record:

No Record:

Contact Information