Criminal History Form
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10 JOHNSTON COUNTY 911 COMMUNICATIONS SMITHFIELD , NC 27577 Fax 919 - 989 - 5009 CRIMINAL HISTORY FORM Note Purpose Code , Authorizing Signature and date are Mandatory Note Must be Criminal Justice employment only Note Purpose Code J CANNOT just list Employment , must list if it’s for a Police Office Job , Police Records clerk , Animal Control , etc … Requesting Officer _____________________________________________ Authorized Agency _____________________________________________ Date of Request _____________________________________________ 1 Name ______________________________________________________________________ Race _______________ Sex _______________ DOB ______________________ SS # ____________________________ Case # ____________________________ Offense Charge _____________________________________________________________ Purpose Code Criminal C ______________________________________ Employment J ______________________________________ List type of Criminal Justice employment here See note above Housing Authority H ______________________________________ 2 Name ______________________________________________________________________ Race _______________ Sex _______________ DOB ______________________ SS # ____________________________ Case # ____________________________ Offense Charge _____________________________________________________________ Purpose Code Criminal C ______________________________________ Employment J ______________________________________ List type of Criminal Justice employment here See note above Housing Authority H ______________________________________ Authorized Signature of Approval ______________________________ Date of Authorization Signature ______________________________Page