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DAWSON COUNTY SHERIFF’S OFFICE SHERIFF JEFF JOHNSON 19 Tucker Avenue Dawsonville, Georgia 30534 Office (706) 344-3535 ~ Fax (706) 344-3537 SIGNATURE OF RECEIVING PERSON NOTARY SIGNATURE To be completed by Dawson County Sheriff’s Office personnel: Case number or criminal history number used: Select purpose code used: C E F J M N P U W Z Special employment provisions (check if applicable): Employment with mentally disabled (Purpose code Employment with elder care (Purpose code Employment with children (Purpose code Date of inquiry: Time of inquiry: Operator’s initials: CRIMINAL HISTORY REQUEST I hereby request for the Dawson County Sheriff’s Office to retrieve any criminal history record information, which may pertain to myself (or the person named below), that may be found in any state or local criminal justice agency in Georgia. Records obtained from the Dawson County Sheriff’s Office shall only be used by the requesting agency or individual solely for the purposes requested. If any information is used to deny employment or license, it shall not reflect on the liability of this office, but on the agency or entity who makes that decision and to allow the person/applicant a chance to dispute any information which may be in error. Any dissemination of the information provided must be with permission of the person/applicant. Dawson County shall not be held responsible for information obtained by another agency, state or federal, which provides such information and whose files reflect records which may contain errors or omissions. TO ENSURE ACCURACY, PLEASE PRINT AND PROVIDE COMPLETE INFORMATION: Date of Request: Authorization good for: 7 30 90 180 days Agency requesting criminal history (name and phone Full Name: Phone Address: SSN: Providing your SSN is voluntary, SSN helps confirm your identity and history. Date of Birth: Sex: Race: Height: Hair: What STATE were you born in?: Individual(s) authorized to receive criminal Massey and Angela Any authorized individual(s) must present a valid identification upon receipt of this criminal history. If a valid identification cannot be presented, the criminal history will not be released. SIGNATURE OF APPLICANT NOTARY STAMP SIGN SIGN SIGN