NEW
    ORLEANS
    POLICE
    DEPARTMENT
    RECORDS
    AND IDENTIFICATION DMSION
    715
    soum
    BROAD
    AVENUE
    NEW
    ORLEANS,
    LOUISIANA 70119
    The applicant listed below has
    policy. we are
    requesting
    a
    ch«:k of your arrest
    records
    to detennine if the
    applicant has
    ever been
    convicted of any
    ~ate or municipa1
    violation in yom'
    jurisdiction.
    The
    applicant
    has
    been
    made
    aware
    of our policy and
    by his signature.
    is personally a~able
    to release
    the
    requested
    infonnaboO. All
    infonnahoo will
    be
    held in strict confidence
    between
    the
    company
    and
    the
    applicant.
    A self address
    stamped
    l."Dvelope
    is
    enclosed
    tor return mailing.
    COMPANY
    NAME
    ,­
    j
    ADDRESS
    CITY I ST
    A
    IE
    I ZIP
    PRJNT
    NAME OF
    COMPANY
    ()fFICIAL
    SIGNATURE
    OF
    C()MPANY ()fFICIAI.
    I\PPlIC.­\J."IiT
    INFORMt\
    TION
    {pLE,'\SE
    PRlNT
    ,\LL INFORMATION
    EXCEPT
    ~l
    A
    TURf}
    NAME
    ,.
    ;
    R.\l'l.:
    SEX
    .illDRESS
    ­­~'!!'­
    i­STATE
    OF BIRTH
    DATE OF
    BIRTH
    SO(.'tAL
    SECURITY
    NUMBER
    (APPLICANT'S
    SIGNA
    nJRE)
    BY THIs SIGNATURE,
    I AUTHORIZE THE RELE.~SE
    OF ~fY ARREST
    CONVICTION RECORD
    AND W
    Al
    S{
    rCH
    LEGAL
    RJGHTS
    THAT MAY ARISE ()(JT OF THE Rf:LEASE
    AND I DO RELEASE
    ALl, PER.~)NS
    FROM
    UABn.IT
    IN
    CONNECTION WInI
    THE RELEASE OF THIS INFORMA nON.
    I
    POLICY
    PERMITS
    THE RELEASE
    OF ONt Y THOSE
    ClIAR(jES THAT HAVE RESlTt
    TED IN A CONVICTI IN.
    THE RESL'L
    IS OF THIS CHECK WERE
    COMPILED
    FROM
    INFO~{.i\ nON OBTAINED ONt Y IN OUR
    JtJRISDI<"T
    ON.
    DATE
    OFFENSE
    DISPOSITION
    IMPORTANT
    ­
    THE DEPARTMENT
    OF POLICE CANNOT MAKE AN ACCURATE IDENTIFICATION
    BASE
    UPON
    NAME AND DATE OF BIRTH ONt Y. ANY INFORMATION
    CONTAINED
    ON ANY NAME CHECK IS SUBJECT TO
    VERlFICAnON
    BETWEEN THE REQUESTING PARTY AND THE APPLICANT.
    THE NEW ORLEANS POLICE
    IF THE IMPRINT OF THE SEAL IS NOT AFFIXED TO THIS FORM THROUGH
    PAGE TWO ATTACHED
    NOPD
    FROM
    #22
    (Rev.
    01101)
    REQUEST
    FOR
    CRIMINAL mSTORY
    lNFORMA
    TION
    to this company
    for consideration
    of a
    service
    by the
    company.
    As part of our
    provided
    RECORD
    DIVISION CLERK
    IDA
    TE

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