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Nebraska State Patrol Criminal History Record Request Form Date: This request is on: (check one) Yourself Someone Else Person of Interest Name (Last, First, MI): ALIAS / AKA: List any other names used: maiden, married, adopted, nicknames, short names, etc. This request will not be denied for refusal to provide a social security number, but the criminal history check may take longer without the number, which will be used only for the purpose of confirming identity during the criminal history check. SSN: DOB: Current Address: City, State, Zip: Fax #: (If results should be faxed) Sex Race Individual Or Agency (Only if different than above) Agency: Individual Requesting Data: Mailing Address: City, State, Zip: Fax #: (If results should be faxed) Signature of Requester (Individual or Agency) You can either mail your request or come in person to: Nebraska State Patrol Criminal Identification Division 3800 NW 12th Street – Suite A Lincoln, NE 68521 There is a $15.00 fee for this service. This fee is accepted as cash, cashier's check, personal check or money order. Make checks payable to Nebraska State Patrol. If mailing a request for a criminal history on yourself or you as the requester require activity excluded by §29-3523, you may need to have this request form notarized. See §29-3523 for more information. If needed, notary acknowledgment is below. Note: All convictions are released without notarization. I consent to the disclosure and copying of any Record of Arrest of Prosecution to the above listed persons. State of ___________________ ) Signature of Person of Interest )ss County of __________________ ) Subscribed and sworn to before me this day of Notary Public NSP752 (09/11) , .