HTML Preview Request For Criminal Record Check Form page number 1.
SP 4-164 (12-99)
PENNSYLVANIA STATE POLICE
REQUEST FOR CRIMINAL RECORD CHECK
PART I: TO BE COMPLETED BY REQUESTER
(INFORMATION WILL BE MAILED TO REQUESTER ONLY)
DATE OF REQUEST
*** TYPE OR PRINT LEGIBLY WITH INK ***
NOTE: IF THIS FORM IS NOT LEGIBLE OR NOT PROPERLY COMPLETED, IT WILL BE RETURNED UNPROCESSED TO THE
REQUESTER. A RESPONSE MAY TAKE THREE WEEKS OR LONGER TO PROCESS.
WARNING: A PERSON COMMITS A MISDEMEANOR OF THE THIRD DEGREE IF HE/SHE MAKES A WRITTEN FALSE
STATEMENT, WHICH HE/SHE DOES NOT BELIEVE TO BE TRUE.
REQUESTER
NAME
ADDRESS
CITY
STATE
ZIP
CONTACT TELEPHONE NUMBER (INCLUDING AREA CODE)
- -
FOR CENTRAL REPOSITORY USE ONLY
(LEAVE BLANK)
REQUESTER IDENTIFICATION (ONLY CHECK ONE BLOCK)
INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE A CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF $10.00 PAYABLE TO: “COMMONWEALTH OF PENNSYLVANIA.”
THE FEE IS NONREFUNDABLE.
FEE EXEMPT NONCRIMINAL JUSTICE AGENCY
*** DO NOT SEND CASH OR PERSONAL CHECK ***
NAME/SUBJECT OF RECORD CHECK (LAST)
(FIRST)
(MIDDLE)
MAIDEN NAME AND/OR ALIASES
SOCIAL SECURITY NUMBER (SOC)
DATE OF BIRTH (DOB)
SEX
RACE
REASON FOR REQUEST (CHECK ONE BLOCK)
EMPLOYMENT (IF APPLICABLE, CHECK ONE OF THE FOLLOWING)
ELDER CARE
CHILD CARE SCHOOL DISTRICT
ADOPTION/FOSTER CARE
OTHER (SPECIFY)
ONLY CHECK THIS BLOCK IF YOU WANT TO REVIEW YOUR ENTIRE CRIMINAL HISTORY
INDIVIDUAL ACCESS AND REVIEW OR FIREARMS CHALLENGE–ENTIRE CRIMINAL HISTORY
(AVAILABLE ONLY TO SUBJECT OF RECORD CHECK OR LEGAL REPRESENTATIVE WITH LEGAL AFFIDAVIT OF LEGAL REPRESENTATIVE ATTACHED)
REQUESTER CHECKLIST
DID YOU ENTER THE FULL NAME, DOB, AND SOC?
DID YOU ENCLOSE THE $10.00 FEE (CERTIFIED CHECK/MONEY ORDER)?
*** DO NOT SEND CASH OR PERSONAL CHECK ***
DID YOU ENTER YOUR COMPLETE ADDRESS INCLUDING ZIP CODE AND
TELEPHONE NUMBER IN THE BLOCKS PROVIDED?
AFTER COMPLETION MAIL TO
PENNSYLVANIA STATE POLICE
CENTRAL REPOSITORY – 164
1800 ELMERTON AVENUE
HARRISBURG, PA 17110-9758
717-783-9973
BUSINESS HOURS 8:15 am - 4:15 pm (Monday – Friday)
PART II: CENTRAL REPOSITORY RESPONSE ONLY ***DO NOT WRITE BELOW THIS LINE***
INFORMATION DISSEMINATED
NO RECORD
CRIMINAL RECORD ATTACHED
INQUIRY DISSEMINATED BY
SID NUMBER
THE INFORMATION DISSEMINATED BY THE CENTRAL REPOSITORY IS BASED ON THE
FOLLOWING IDENTIFIERS THAT MATCH THOSE FURNISHED BY THE REQUESTER.
NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH RACE
SEX
MAIDEN/ALIAS NAME
CERTIFIED BY
(DIRECTOR, CENTRAL REPOSITORY)
This response is based on a comparison of data provided by the requester in Part I against the information contained in the files
of the Pennsylvania State Police Central Repository only, and does not preclude the existence of criminal records which might be
contained in the repositories of other local, state, or federal criminal justice agencies.