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8 6. Return the request to Criminal Records Section North Dakota Bureau of Criminal Investigation 4205 State Street PO Box 1054 Bismarck ND 58502-1054 701 328-5500 Use street address when shipping by next day service. Background request only covers North Dakota criminal history records. 3. State law NDCC 12-60-16. 6 requires the subject s name and at least two other provided items of information match the data in the criminal history record system before a record may be released. Providing maiden or former names is very important. 12-60-16. 6. Disclosure of your social security number is voluntary. However not providing this information will result in the requirement that other information be provided including a reportable criminal event or the submission of fingerprints. SID Number Released Date Y/N P/P OFND LTR INFORMATION CONTAINED ON THIS RECORD REQUEST FORM IS SUBJECT TO THE NORTH DAKOTA OPEN RECORDS LAW.. NON-CRIMINAL JUSTICE REQUEST FOR CRIMINAL HISTORY RECORD INFORMATION Check Number OFFICE OF ATTORNEY GENERAL BUREAU OF CRIMINAL INVESTIGATION Amount Receipt Number SFN 50744 05/14 Receipt Date FOR BCI USE ONLY INSTRUCTIONS 1. Please type or print legibly and ensure that all information is complete. Incomplete or illegible requests will be returned* 2. Please ensure Social Security Number and Date of Birth are provided and are correct. A set of fingerprints is not required but may be submitted* 4. The required 15. 00 fee U*S* Dollars per record check must be included with this request. The check or money order must be made payable to the North Dakota Attorney General* 5. To complete the criminal history record check we must have a signed authorization form SFN 51156 from the subject OR the subject s current address. If a signed authorization form is not provided state law requires BCI provide notice to the subject if a record is disseminated* NDCC 12-60-16. REQUESTER INFORMATION - RESULTS WILL BE MAILED TO INDIVIDUAL OR COMPANY INDICATED IN THIS BLOCK Mail to Attention of Telephone Number Name/Company Address City State ZIP Code RECORD CHECK WILL BE CONDUCTED ON INDIVIDUAL LISTED BELOW Last Name First Name no initials Middle Name AKA/Maiden/Former Last Name s First Name Date of Birth MM/DD/YYYY Social Security Number BCI State ID Number if known Specific reportable criminal event identified by date offense and agency or court if known Current Address If current address is not furnished a signed authorization form must be attached Your social security number is requested to permit the North Dakota Bureau of Criminal Investigation to conduct a criminal history record information background investigation under N*D*C*C. 12-60-16. 6. Disclosure of your social security number is voluntary. However not providing this information will result in the requirement that other information be provided including a reportable criminal event or the submission of fingerprints. SID Number Released Date Y/N P/P OFND LTR INFORMATION CONTAINED ON THIS RECORD REQUEST FORM IS SUBJECT TO THE NORTH DAKOTA OPEN RECORDS LAW*.

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