Hawaii Criminal Justice Data Center
REQUEST FOR CRIMINAL HISTORY RECORD CHECK
For Hard-copy Fingerprint Cards
Reason for Request: Fees below include hard-copy fingerprint card processing fee
Name-Based Search ($30) Fingerprint-Based Search ($35)
Access and Review ($35) Wrongful Use of Name/SSN ($35)
Other: Certify ($20) Notarize
Part 1: To be completed by applicant. Please clearly print all requested information regarding the
person on whom the criminal record check is being conducted.
Full Name: Last First Middle Suffix (Jr/Sr)
Alias/Maiden: Last First Middle Suffix (Jr/Sr)
Date of Birth:
Place of Birth:
Citizenship:
Social Security Number:
Race:
Black Chinese Filipino Hawaiian Hispanic
Japanese Korean Native American Other
Samoan Tongan Unknown White
Sex: Male
Female
Height:
Weight:
Eye Color:
Hair Color:
Part 2: To be completed by applicant. Please clearly print all the information requested below.
Requestor's Name and Address Forward Results to (if different from Requestor):
Name:
Name:
Address & Phone:
Address:
Requestor's Signature:
Date:
Part 3: To be completed by Fingerprinting Agency (Law Enforcement Only). Please seal fingerprint
card in a stamped envelope to preserve chain of custody.
Type of ID Checked & ID No.:
F/P Agency Name:
F/P Agency Phone Number:
Fingerprinter Name:
Fingerprinter Signature:
Date Fingerprints Taken:
Part 4: To be completed by HCJDC Only
Type of Search:
Name
Fingerprint
Results:
Full
No Match No Conv
Match SID: Conv Only
Completed by:
Date:
Mail form, payment, and fingerprint card (if applicable) to:
Hawaii Criminal Justice Data Center, Attn: CHRC
465 S. King Street, Room 102
Honolulu, HI 96813
Fee is payable by either cashier's check or money order to:
"Hawaii Criminal Justice Data Center"
Personal checks are not accepted.
For more information call (808) 587-3279 or visit
http://ag.hawaii.gov/hcjdc
orm HCJDC-073 Revised 06/2012
