ALABAMA LAW ENFORCEMENT AGENCY
APPLICATION TO REVIEW ALABAMA CRIMINAL HISTORY RECORD INFORMATION
PERSONAL INFORMATION
Full Name (First, Middle, Last, Suffix): Sex/Gender: Male Female
Aliases/Nickname:
Applicant Current Address:
City: State: Zip Code: SSN:
Date of Birth: (MM/DD/YYYY) Driver’s License Number: Issuing State:
Race: White Black Asian Indian Other (please specify)
Home Phone: ( ) Mobile Phone: ( ) Work Phone: ( )
WORK INFORMATION
Employer Name: Employer Phone: ( )
Contractor Name: Contractor Phone: ( )
State Agency: Agency Phone: ( )
Work Email Address:
Job Role/Classification: Supervisor Name:
Included with my Release are the following items:
Completed Application signed by applicant and two witnesses OR notarized.
The required copy of my valid photo identification.
A classifiable copy of my own fingerprints taken by an authorized law enforcement agency as required.
If applying for state employment/licensure/certification, reference that agency’s fee requirements for a background check.
AFFIDAVIT FOR RELEASE INFORMATION
I hereby authorize the Alabama Law Enforcement Agency to release any and all criminal history information to:
Name & Address of Requesting Agency or Authorized Agent*
I, the above referenced individual, hereby request to release any and all criminal history record information (CHRI) maintained by both the Alabama Law Enforcement
Agency, the Federal Bureau of Investigation, and any information relating to my past record and character whether it be financial, academic, military, employment,
judicial, or personal reference. I hereby release all parties contributing such information from any charges or liability whatsoever because of furnishing said information.
By signing below and submitting this application, I hereby verify that the information listed in my application and in the attached documentation is correct. I also
acknowledge that I understand that, in accordance with Section 41-9-601 of the Code of Alabama 1975, that any person who willfully requests, obtains or seeks to
obtain criminal offender record information under false pretenses, or who willfully communicates or seeks to communicate criminal offender record information to any
agency or person without authorization, may be guilty of a felony, and shall be fined not less than $5,000 nor more than $10,000 or imprisoned in the state penitentiary
for not more than five years or both. § 41-9-601, Code of Ala. (1975). Furthermore, as set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34 I have the
right to challenge or appeal any portion of my state and/or federal CHRI that I believe to be inaccurate (see “Appendix A” for contact information).
Applicant Signature Date
Name of Witness Name of Witness
Address of Witness Address of Witness
City, State and Zip City, State and Zip
Sworn to and subscribed before me this ____ day of _________________, 20___.
Notary Signature _____________________________ My Commission Expires ________________, 20___.
ALABAMA LAW ENFORCEMENT AGENCY
FOR ALEA OFFICIAL USE ONLY: TCN: ______________________ SID: AL_______________________
Received By (Initials): ________/Date: ___/___/___ Processed By (initials): ________/Date: ___/___/___
Walk-in/Hand Delivered ____ Mailed ____ Status: ________ Initials: ______ Date: ___/___/
____
Billed: ______ Paid: ______ No Charge: ______
Check#: ________________________________
Background Check Qty: ___ Total: $_________
Certified Letter Qty: ___ Total: $_________
SBI Form 46 Rev. 10-01-17
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