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“An Equal Opportunity Employer” Current as of 9-20-24 PHOTO ID “An Internationally Accredited Agency” COLUMBIA COUNTY SHERIFF’S OFFICE Clay N. Whittle, Sheriff 2269 COUNTY CAMP ROAD POST OFFICE BOX 310 APPLING, GEORGIA 30802-0310 (706) 541-1043 CRIMINAL HISTORY CONSENT FORM I, (Complete Full Name) hereby request to receive the Criminal History Record Information pertaining to me which may be in the files of the Georgia Crime Information Center relating to my record with any Criminal Justice Agency providing that information. I expressly release the Columbia County Sheriff’s Office from any and all liability claims relating to the acquisition and release of any information pertaining to me. This authorization is valid for days from date of signature. Print the following information: Full Name: Address: City, State, and Zip Code : Telephone: Sex: Race: Hair Color: Eye Color: Height: Weight: Date of Birth: Place of Birth: SSN: REASON FOR REQUEST: __Child Abuse [DFCS] (Case # *must have copy of report attached Neglect (DFCS) Adoption Foster Care Alcohol License Other Special employment provisions (check if applicable) Employment with mentally disabled (Purpose code Employment with elder care (Purpose code Employment with children (Purpose code Employment with criminal justice agency- non-sworn (Purpose code Employment with criminal justice agency – sworn (Purpose code Personal Copy - Record Review (Purpose code Employment (Purpose code I hereby Certify, by my signature below, that all of the above information is TRUE. I further authorize the below listed individual to receive my Criminal History Record Information from the Columbia County Sheriff’s Office. Any alteration of this form after completion may lead to prosecution. SIGNATURE DATE NAME OF AGENCY / INDIVIDUAL TO RECEIVE RECORD ***THIS FORM MUST BE FILLED OUT COMPLETELY AND NOTARIZED FOR RELEASE OF INFORMATION*** NOTARY SIGNATURE DATE NOTARY SEAL HERE The official response to this request will bear a raised seal over the photo ID and a red ink stamp SIGNATURE DATE