GCIC Background form
I hereby authorize Alto Police Department to conduct an inquiry for Agency/Company
(company) with the purpose(s) listed below and receive any Georgia and/or national criminal background history record information as authorized by state and federal law.
Full Name (print):
Date of Birth:
Social Security Number:
This authorization is valid for 90 days from date of signature.
I, give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment.
Purpose Code Used: (check all one that applys)
Official use only:
Inquiry: Time of Inquiry: Operator’s Initials:
The inquiry resulted in the following: (check all that apply)
Wanting Agency Name: Wanting Agency Telephone:
Agency Designee Signature and Title Date
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: GCIC Background form
Agree & Sign