SOP 109.01-att-4: Volunteer Services GCIC_NCIC Consent Form

SOP 109.01
Attachment 4
6/30/20

VOLUNTEER SERVICES

GCIC/NCIC CONSENT FORM

I, ________________________________, hereby authorize the Georgia Department of Corrections (GDC) to
receive any criminal or driver ' s license history information, at any time, pertaining to me which may be in the files
of any state or local criminal justice agency.

Full Name Printed:

Address:

City and State Zip Code Place of Birth

Weight Height Hair Eyes

Sex Race DOB SSN

Applicant’s Signature Date

Approved/Di sapproved (circle one) Comments: _________________________________________

______________________________________________________________ _________________
Appointing Authority’s Signature Date

___________________________________________________________ _________________
Institution/Center/Office Date

For Ex-offenders ONLY : Approved/Disapproved by Regional Director

Signature Date

(To be placed in personnel file at Facility)

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.