Authorization Form
for Release of File Copies
of  Criminal History Records
for the State of Georgia

I hereby authorize Interstate Background Research, Inc. acting as an agent for __________________________________________ to receive any criminal history record information pertaining to me, which may be in the files of any state or any local criminal justice agency, or any law enforcement agency.
This request is specifically for, all agencies within, and the State of Georgia.
This request/release is valid for one (1) year from this date hereon.

PART A: To be completed by EMPLOYEE:

                          Employee Social Security Number: _______-_____-________

                    *Employee Date of Birth: ____/____/_______ *Gender: ________

              Employee Full Name: ______________________________________

       Employee Street Address: ______________________________________

Employee City, State and Zip: ______________________________________

               Date of this request: ___/___/______

Signature of Employee: _______________________________ ** SIGN HERE

THANK YOU

* May be deemed necessary to conduct a thorough criminal record search in accordance with the, "Code of Federal Regulations" Equal Employment Opportunity Commission Code 1625.5.

* This request for your date of birth does not indicate discrimination; and the request in itself is not a violation of the Age Discrimination Act. Your date of birth is requested for a permissible purpose, under the code, and has been ruled a critical identifier for criminal and driving history information. Some states will not conduct a criminal search without the date of birth.

form crim_rel_ga    rev 10/18/2001