Asp 122 Form – Fill Out and Use This PDF

ARKANSAS STATE POLICE	ASP 122
	(Rev. 02/19/2019)

Identification Bureau

Individual Record Check Request Form

INSTRUCTIONS

If you are mandated by law to have the background check performed, please contact the licensing agency/entity that requires the background check for the proper request form.

1.When an Arkansas background check is requested, include a properly completed ASP 122 request form and a check or money order in the amount of $25.00 (DO NOT SEND CASH), made payable to the Arkansas State Police. A fingerprint card is NOT required to be submitted if only the Arkansas background check is requested. The results of the Arkansas background check will be sent to the person/entity as specified on this form.

2.The subject of the criminal records search may challenge the completeness or accuracy of the criminal history information by using the procedures as outlined in Title 28, Code of Federal Regulation (CFR) Section 16.34 and/or Arkansas Code §12-12-1013.

3.If the request is made by mail, an envelope properly addressed to the person/entity to whom the background check will be released, as specified on the ASP 122 form, with sufficient return postage must be included.

4.When the properly completed ASP 122 form is submitted, other than in person at the ASP ID Bureau in Little Rock by the subject of the record check, this request form must be notarized.

5.Send properly completed request form, envelope, and proper payment to:

Arkansas State Police

Identification Bureau

1 State Police Plaza Drive

Little Rock, AR 72209

To contact the Arkansas State Police ID Bureau, you may call 501-618-8500.

SEE OTHER SIDE FOR REQUEST FORM

Front

ARKANSAS STATE POLICE	ASP 122
	(Rev. 02/19/2019)

Identification Bureau

Individual Record Check Request Form

Last Name

First Name

Middle Name

Jr./Sr./III

Daytime Phone #:

List ALL other names ever used (married, maiden, shortened, etc.)

Date of Birth:

State of Birth:

Race:

Sex:

(Month/Day/Year)

Social Security #:

Driver’s License #:

State

Mailing Address:

Street/P.O. Box

City

State

Zip Code

APPLICANT RECORD NOTICE

Obtaining Copy: Procedures for obtaining a copy of the FBI criminal history record are set forth in Title 28, Code of Federal Regulations (CFR) Section 16.30 through 16.33 or the FBI website at http://www.fbi.gov/about-us/cjis/background- checks.

Change, Correction, or Updating: Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth in Title 28, Code of Federal Regulations (CFR), Section 16.34.

I give my consent for the Arkansas State Police to conduct a criminal record search on myself and release any results to the following person or entity:

Signature:		Date:
	(First/MI/Last Name)		(Month/Day/Year)

Release to:

(First/MI/Last Name) OR Full Name of Agency

Mailing Address:

Street/P.O. Box

City

State

Zip Code

WHEN THIS PROPERLY COMPLETED REQUEST FORM IS SUBMITTED {OTHER THAN IN PERSON BY THE SUBJECT OF THE

CHECK} THIS REQUEST FORM MUST BE NOTARIZED

STATE OF

COUNTY OF

Subscribed and sworn before me, a Notary Public, in and for the county and state aforesaid, this is the

day of			, 20	.
				Notary Public

BELOW FOR OFFICE USE ONLY

82005 State Record Check

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