Dps 125C Form – Fill Out and Use This PDF

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

STATE POLICE BUREAU OF IDENTIFICATION

STATE OF CONNECTICUT

CRIMINAL HISTORY RECORD REQUEST FORM

(PLEASE TYPE OR PRINT CLEARLY)

Check Type of Background Search Requested:

() CT Only search by Name/Date of Birth-$36.00 (will only provide existence of a record and not actual record)

() CT Only Criminal Conviction History Record Search-$75.00 (Name/DOB Search will provide a copy only if a record exists)

() CT Only Criminal Conviction History Record searched by Fingerprint-$75.00*

*Fingerprinting completed at a Connecticut State Police location - $15.00

Name of Requester:____________________________________Date:____________________

Requester Address:____________________________________________________________

City:___________________State:______Zip:________Phone Number:___________________

E-Mail Address:________________________________________________________________________

(NOTE: If e-mail address is provided, results will be sent solely via e-mail)

1.Print full name and date of birth, maiden or alias names for each subject requested.

2.If a fingerprinted criminal history record check is required submit a Fingerprint card along with this form.

3.Enclose a Check or Money Order for the applicable amount made payable to:

“Treasurer-State of CT”

4.If you are requesting more than one name please submit one check for the total dollar amount of all subjects requested. A separate form will be required for each search requested.

5. Mail Request with Check or Money Order to:	DESPP-SPBI
	1111 Country Club Road
	Middletown, CT 06457-2389

___________________________________________________________________/___/_______

Subject’s Last Name

First

Middle

Date of Birth

List any alias or maiden names and dates of births used:

______________________________________________________________________________________________

The result of this search is based on name and date of birth or fingerprint card submission and contains State of Connecticut criminal conviction history record information ONLY. Please be advised that the criminal history record information may change daily due to erasures, corrections, pardons or other modifications to individual criminal history record information, the Department of Emergency Services and Public Protection (DESPP) cannot guarantee the accuracy of the information except with respect to the date the information is disclosed or obtained. DESPP and the State of Connecticut are not responsible for any errors or omissions resulting from subsequent dissemination of this data. The subject and/or requester assumes all liability in the use of data obtained from this database.

**A COPY OF THIS FORM MAY BE USED**

Phone: (860) 685-8480 Fax: (860) 685-8361

1111 Country Club Road

Middletown, CT 06457-2389

An Affirmative Action / Equal Opportunity Employer

DPS-0846-C (REV. 12/01/17)

Form Available @ www.ct.gov/despp