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T h o m a s H . S m i t h S h e r i f f O f f i c e o f t h e S h e r i f f o f W a s h i n g t o n C o u n t y Post Office Drawer 30 • Sandersville, Georgia 31082 (478) 552-4795 • Fax (478) 552-5848 CRIMINAL HISTORY RECORD INFORMATION CONSENT/INQUIRY FORM I hereby authorize the Washington County Sheriff’s Office to conduct an inquiry for the purpose(s) listed below and receive any Georgia and/or national criminal history record information, as authorized by State and Federal law. Full Name (Print) Address Sex Race Date of Birth Social Security Number This authorization is valid for days from date of signature. I, give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment. Signature Date Signature of Employment Release Agency, Title Date OFFICIAL USE ONLY – DO NOT FILL Date of Inquiry: Time of Inquiry: Operator Initials:__________ Purpose Code Used: (Check all that apply) E – Employment / Rental M – Working with Mentally Disabled N – Working with Elderly W – Working with Children The inquiry resulted in the following: (Check all that apply) No Criminal Record Available Criminal Record (Attached / Released) No NCIC/GCIC Warrant Possible NCIC/GCIC Warrant (List Wanting Agency Below) Wanting Agency Wanting Agency Designee