GCIC Background form

Name-Based Criminal History Record Information Consent/Inquiry Form


I hereby authorize Alto Police Department  to conduct an inquiry for Agency/Company

(company) with the purpose(s) listed below and receive any Georgia and/or national criminal background history record information as authorized by state and federal law.

Full Name (print):

AKA name(s):




Date of Birth:

Social Security Number:

This authorization is valid for 90 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.


Purpose Code Used: (check all one that applys)


Official use only:

Inquiry: Time of Inquiry: Operator’s Initials:

The inquiry resulted in the following: (check all that apply)

Wanting Agency Name:  Wanting Agency Telephone:



Agency Designee Signature and Title                                                                    Date

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: GCIC Background form
lock iconUnique Document ID: 37b1c411a142ce5ecfa452f3099b57da290797f1
Timestamp Audit
August 11, 2021 8:14 am ESTGCIC Background form Uploaded by Sapphire check - support@sapphirecheck.com IP