Criminal History Consent Form REQUEST TO RESTRICT ARREST RECORD *Misdemeanor record restriction only, felony records will not be restricted* *Any applicant with open warrants will not have their application processed* First Name * Middle Name Last Name * Maiden Name Address * Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal What is the best way to reach you? * Phone Text Email Will you need a translator? * Yes No If yes, what language? * Are you currently on probation or parole in any county (misdemeanor, felony, or non-reporting)? * Yes No If yes, please enter any additional information * Do you have a pending criminal case in any jurisdiction? * Yes No If yes, please enter any additional information * Sex * Male Female Race * American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Date of Birth * Social Security Number * Phone * Email * Arresting Agency * What City did this incident happen in? * RiverdaleJonesboroLovejoyLake CityCollege ParkForest ParkMorrow Date of Arrest * Offense(s) Arrested For * 0 of 400 max characters * I request the arrest record information (Date of Arrest and associated charges) described above pertaining to me be restricted from the record(s) of the arresting agency pursuant to the provisions of O.C.G.A. §35-3-37. Signature * signature keyboard Clear Date * Name-Based Criminal History Record Information Consent/Inquiry * I hereby give my consent for the Clayton County Record Restriction Event Partners (Clayton County Solicitor General, Clayton County Sheriff’s Office, Clayton County Police Department, and Municipal City Solicitor) to retrieve my Georgia Crime Information Center (GCIC) criminal history under purpose code U for purposes of reviewing my record to determine restriction (restriction and sealing) eligibility. I understand that my GCIC criminal history will be shared with the Georgia Justice Project (a non-profit law firm) for review and consultation through the Clayton County Record Restriction Event. * This authorization is valid for 365 days from date of signature. * Limited Scope Representation – Georgia justice Project (GJP), a non-profit organization, will be my attorney for purposes of receiving and reviewing my GCIC criminal history report in connection with my application for record assistance through the Clayton County Record Restriction Event. GJP will not disseminate or share my GCIC report beyond staff or volunteers assisting with the Clayton County Record Restriction Event without my permission. GJP will not become my attorney for any other purpose absent a fully signed representation agreement between me and the Georgia Justice Project. Signature * signature keyboard Clear Date * Notes for Applicant - If you have any of the following documents, please bring them to your appointment: Case documents for charges you want expunged Case documents for other charges on your record Job or housing denials due to your record Denials or communications from occupational licensing boards Prior requests to clean up your record Captcha Submit If you are human, leave this field blank.
