Release of Information Form

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby request and authorize the Kansas Bureau of Investigation to furnish the above-named facility with criminal history information as described in K.S.A. 2019 Supp. 22-4701(b). This includes all information defined with K.A.R. 10-9-1 (b)(c) and (d).

Full Name *

Alias (Including Maiden)

Current Address *

Sex *

Race *

Driver's License Number *

Signature (Type Full Name) *

Date *

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