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Richmond Police Department
Records Division
Please be advised, this is a local (Richmond) record check only. If you desire state and county record
checks, you must contact those agencies for that additional information.
50 North 5th Street
Richmond, IN
765-983-7247
APPLICANT FULL NAME:________________________________________________________________
PRESENT ADDRESS:_____________________________________________________________________
CITY, STATE, ZIP CODE:_________________________________________________________________
ALIAS AND/OR OTHER NAMES (MAIDEN):________________________________________________
DATE OF BIRTH:_______________ SOCIAL SECURITY#:___________________________
TODAY’S DATE______________
I, ___________________________________, HEREBY GIVE AUTHORIZATION TO THE RICHMOND,
INDIANA POLICE DEPARTMENT TO RELEASE ANY INFORMATION CONCERNING MY RECORD
AND/OR ARRESTS, OR PENDING WARRANTS THAT I MAY HAVE.
_______________________________
APPLICANT SIGNATURE
(BELOW PORTION TO BE FILLED OUT BY RECORDS CLERK ONLY)
DOES APPLICANT HAVE A RECORD? _____YES _____NO
See Additional _____of pages of record.
COMMENTS:______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________ ___________
RECORD’S CLERK SIGNATURE DATE
P: 765-935-5655 F: 765-935-6164 Email: vanvleet@vanvleetinsurance.com
Dept.__________
DISCLOSURE CONSENT
FOR PROCUREMENT OF
MOTOR VEHICLE REPORT FOR
EMPLOYMENT & DRIVING PURPOSES
The undersigned hereby authorizes City of Richmond, or its insurance agency,
VanVleet Insurance, or its assigns, to obtain copies of Motor Vehicles, pertaining
to me for employment &/or driving purposes, and for use in rating and/or
underwriting insurance for which the above names employer may apply, and any
renewal thereof.
DATE:______________________ SIGNED: ________________________________
____________________________ _________________________________________
Date of Birth Printed Name
____________________________ _________________________________________
Driver’s License Number State of Issue
For Office Use Only:
______ Approved
______ Watch Basis
______ Not Approved
Valid Class A CDL / Class B CDL ______ _____
YES NO
Type of Endorsements: _______________________________________________________
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