Utah > Statewide > Juvenile
Application For Criminal History Record (Juvenile) - Utah
| Application For Criminal History Record (Juvenile) Form. This is a Utah form and can be used in Juvenile Statewide . |
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APPLICATION FOR CRIMINAL HISTORY RECORD Utah Department of Public Safety · Bureau of Criminal Identification 3888 West 5400 South, Taylorsville, Utah 84129 Telephone: (801)965-4445 form 98-1-03, Rev 6/2011 BUREAU USE ONLY WHEN FILLING OUT THIS APPLICATION TYPE OR PRINT IN BLACK INK. Your application will not be processed unless all sections of this form are filled out completely. You will need a valid form of government issued picture ID and $15.00 fee. NAME: (Last Name) (First Name) (Middle Name) DATE OF BIRTH________________ PREVIOUSLY USED NAME(S) (Maiden, etc.): _______________________________________________________________________ MAILING ADDRESS: ___________________________________________________________________________________________ (Street/Box number) (Street) (City) (City) (State) (State) (Zip) (Zip) PHYSICAL ADDRESS: __________________________________________________________________________________________ HOME PHONE NUMBER: SOCIAL SECURITY: PHYSICAL DESCRIPTION: HGT/ WGT/ DAYTIME PHONE NUMBER: __________________________________ DRIVER LICENSE # AND STATE: _________________________________ EYE COLOR/ SEX/ RACE/___________ I hereby declare that I am the person listed above and am entitled to my criminal record as provided by Utah Code Ann. § 53-10-108(8)(a). The information contained in this written statement is true and correct to the best of my knowledge and I understand that any false statements I make that I do not believe to be true may subject me to criminal punishment as a class B misdemeanor pursuant to Utah Code Ann. §76-8-504. Signature of applicant: Date: ___________________________ FINGERPRINT INSTRUCTIONS: (OFFICIAL TAKING PRINTS) Confirm identity of applicant with identification that shows photo, signature and date of birth. Confirm ID with the information above, then list the type of government issued ID used and the ID number in the space provided below. Fingerprint the four fingers of the applicant's right hand simultaneously in the box located in the lower right portion of this form. APPLICANT IDENTIFICATION INFORMATION Type of identification used: (Utah Driving Privilege Cards are not valid ID and will not be accepted) Identification number: Name on ID: OFFICIAL TAKING PRINTS Fingerprints taken by: Agency Name: Date Printed: BUREAU USE ONLY SID# AFIS Confirmation R&F (PRINT NAME) Badge # (If applicable) FINGERPRINTS METHOD OF PAYMENT - FOR MAIL IN ONLY (Check appropriate box for payment) $15.00 APPLICATION FEE - DO NOT SEND CASH IN THE MAIL PRINT NAME (As it appears on the card): ____________________________________________________________________________ TOTAL AMOUNT OF PURCHASE: $ ZIP CODE FOR MAILING ADDRESS OF CREDIT CARD: ____________ CARDHOLDER SIGNATURE: ______________________________________________ DATE: _______________________ Check, Money Order or Cashier's Check (Payable to "Utah Bureau of Criminal Identification" in the amount of $15.00) Credit Card Visa OR Master Card Fill-out information below to pay by credit card. Credit Card Number * 3 digit control # Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Application for Criminal History Record Enclosed is an application for Criminal History Record from the State of Utah, Department of Public Safety, Bureau of Criminal Identification. Please complete all of the steps described below. Failure to properly complete one of the steps may cause a delay in processing your application. 1. Fill out the top portion of the application. List all of your previous names including married and maiden names. Be sure to read and sign the application. Take the application to a law enforcement agency such as your city police department or county sheriff's office. Request that they print the four fingers of your right hand on the space provided. Make sure the law enforcement official who takes your fingerprints fills out the portion of the application labeled "OFFICIAL TAKING PRINTS." Valid government-issued photo ID must be provided (for example, passport, state ID card, consulate ID card, and driver license.) "Utah Driving Privilege Cards" WILL NOT be accepted by BCI as valid ID. Driving Privilege Cards state on them that they are not to be used as ID. NOTE: The fingerprints may be taken at our office, Bureau of Criminal Identification, 3888 West 5400 South, Taylorsville, Utah. The application fee is $15.00. Select a method of payment by making a check mark in the appropriate box. Checks and money orders must be made payable to "Utah Bureau of Criminal Identification." To pay by credit card (Visa or MasterCard), please fill out the requested information on the application. Credit card numbers must include: the signature of the cardholder, the three-digit control number located on the back of the card, the expiration date, and the zip code of card billing address. Cash is accepted only when applying in person. DO NOT SEND CASH IN THE MAIL. Your report will be mailed to the mailing address indicated on the application form. If the information needs to be sent to a third party, the third party release form must be filled out and submitted along with your application. Mail the application, fee and release form (if applicable) to: UTAH BUREAU OF CRIMINAL IDENTIFICATION 3888 West 5400 South Taylorsville, Utah 84129 The report cannot be faxed or sent by e-mail. 6. If your application is for foreign travel or international adoption, please include a letter or note stating such. 2. 3. 4. 5. If you have questions you may call (801) 965-4445 from 7:00 AM - 6:00 PM Monday-Thursday. Our office is closed Fridays, weekends, and holidays. You may also visit our website at http://publicsafety.utah.gov/bci/ The Bureau of Criminal Identification does not maintain juvenile offender records. Requests for such records must be made directly to the Juvenile Court. American LegalNet, Inc. www.FormsWorkFlow.com
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