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Criminal Record Release Authorization Form - New Hampshire

Criminal Record Release Authorization Form Form. This is a New Hampshire form and can be used in Securities Secretary Of State .
 Print-only pdf Last Modified 4/11/2005
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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 OR 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. Releasees 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: New Hampshire Bureau of Securities Regulation Address: 25 Capitol St. Concord, NH 03301 Applicants Signature: Date: Notarys signature: Date: (Affix Seal) (Com. Exp.) Requestors Signature: Date: Rev: 06/01/94
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