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SP 4 164 12 99 FOR CENTRAL REPOSITORY USE ONLY LEAVE BLANK PENNSYLVANIA STATE POLICE REQUEST FOR CRIMINAL RECORD CHECK DATE OF REQUEST PART I TO BE COMPLETED BY REQUESTER INFORMATION WILL BE MAILED TO REQUESTER ONLY TYPE OR PRINT LEGIBLY WITH INK NOTE IF THIS FORM IS NOT LEGIBLE OR NOT PROPERLY COMPLETED IT WILL BE RETURNED UNPROCESSED TO THE REQUESTER A RESPONSE MAY TAKE THREE WEEKS OR LONGER TO PROCESS WARNING A PERSON COMMITS A MISDEMEANOR OF THE THIRD DEGREE IF HE SHE MAKES A WRITTEN FALSE STATEMENT WHICH HE SHE DOES NOT BELIEVE TO BE TRUE REQUESTER NAME ADDRESS CITY The Franklin Institute 222 N 20th Street Philadelphia PA 19103 STATE ZIP CONTACT TELEPHONE NUMBER INCLUDING AREA CODE REQUESTER IDENTIFICATION ONLY CHECK ONE BLOCK INDIVIDUAL NONCRIMINAL JUSTICE AGENCY ENCLOSE A CERTIFIED CHECK MONEY ORDER IN THE AMOUNT OF 10 00 PAYABLE TO COMMONWEALTH OF PENNSYLVANIA THE FEE IS NONREFUNDABLE XX DO NOT SEND CASH OR PERSONAL CHECK FEE EXEMPT NONCRIMINAL JUSTICE AGENCY NAME SUBJECT OF RECORD CHECK LAST MAIDEN NAME AND OR ALIASES FIRST SOCIAL SECURITY NUMBER SOC MIDDLE DATE OF BIRTH DOB SEX RACE REASON FOR REQUEST CHECK ONE BLOCK EMPLOYMENT IF APPLICABLE CHECK ONE OF THE FOLLOWING X ELDER CARE CHILD CARE SCHOOL DISTRICT ADOPTION FOSTER CARE OTHER SPECIFY Volunteer The Franklin Institute ONLY CHECK THIS BLOCK IF YOU WANT TO REVIEW YOUR ENTIRE CRIMINAL HISTORY INDIVIDUAL ACCESS AND REVIEW OR FIREARMS CHALLENGE ENTIRE CRIMINAL HISTORY AVAILABLE ONLY TO SUBJECT OF RECORD CHECK OR LEGAL REPRESENTATIVE WITH LEGAL AFFIDAVIT OF LEGAL REPRESENTATIVE ATTACHED REQUESTER CHECKLIST AFTER COMPLETION MAIL TO DO NOT SEND CASH OR PERSONAL CHECK PENNSYLVANIA STATE POLICE CENTRAL REPOSITORY 164 1800 ELMERTON AVENUE HARRISBURG PA 17110 9758 DID YOU ENTER YOUR COMPLETE ADDRESS INCLUDING ZIP CODE AND TELEPHONE NUMBER IN THE BLOCKS PROVIDED 717 783 9973 BUSINESS HOURS 8 15 am 4 15 pm Monday Friday DID YOU ENTER THE FULL NAME DOB AND SOC DID YOU ENCLOSE THE 10 00 FEE CERTIFIED CHECK MONEY ORDER PART II CENTRAL REPOSITORY RESPONSE ONLY INQUIRY DISSEMINATED BY INFORMATION DISSEMINATED NO RECORD DO NOT WRITE BELOW THIS LINE SID NUMBER CRIMINAL RECORD ATTACHED THE INFORMATION DISSEMINATED BY THE CENTRAL REPOSITORY IS BASED ON THE FOLLOWING IDENTIFIERS THAT MATCH THOSE FURNISHED BY THE REQUESTER NAME SOCIAL SECURITY NUMBER DATE OF BIRTH RACE SEX MAIDEN ALIAS NAME CERTIFIED BY DIRECTOR CENTRAL REPOSITORY This response is based on a comparison of data provided by the requester in Part I against the information contained in the files of the Pennsylvania State Police Central Repository only and does not preclude the existence of criminal records which might be contained in the repositories of other local state or federal criminal justice agencies
SP 4-164  12-99   FOR CENTRAL REPOSITORY USE ONLY  LEAVE BLANK   PENNSYLVANIA STATE POLICE  REQUEST FOR CRIMINAL RECORD CH...

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Jean-Louis

157062928

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Nathanael 

07/14/2000

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