NCSBI - Access Request Form

CIIS Forms > Access Request Form

Access Request Form

ATTENTION: Before you begin completing this application form, you will need to have some required documentation completed and scanned so it can be attached to this form before it is submitted. You will need a completed Access Agreement, completed regulations forms for each authorized official and if you are allowed access via NCGS 143B-932 - Specialized Populations, you will need proof of qualification.

All fields with BLUE labels are required

Agency Information

Is this a new or renewal Access Agreement Request?:

NewRenewal

Legal Name of Agency:

Doing Business as (DBA):

NOTE: When you choose an Agency Main Type below, Sub Types will be shown for several selections. For example, if you choose Health Care, you will then be given the following sub type options: Adult Care Home, Family Care Home, Home Care, Hospice, Hospital, Mental Health, Nursing Home, Nursing Pool.

Agency Main Type:

Federal Tax ID:

County:

Street Address:

City:

State:

Zip Code:

Mailing Address Same as Street Address?:

YesNo

Information Storage

How will CHRI obtained from the NCSBI and/or FBI be secured/stored?:

Primary Contact

Name:

Email Address:

Phone:

()-

Secondary Contact

Name:

Email Address:

Phone:

()-

Billing Contact

Name:

Email Address:

Phone:

()-

Is billing address same as main address?:

YesNo

Audit Contact

Name:

Phone:

()-

Email Address:

CJIS Online Administrator (CJIS Security Awareness Training Admin)

Name:

Phone:

()-

Email Address:

Statutory Authority

If you do not know which statute to choose, contact DHHS for assistance.
We cannot advise you on which statute to choose.

Statutory authorization which permits requesting Criminal History Record Information (CHRI) :

Comments explaining the organization’s need for an agency account:

List of Authorized Officials

First Authorized Official

Name:

Title:

Email Address:

Phone:

()-

Second Authorized Official

Name:

Title:

Email Address:

Phone:

()-

Third Authorized Official

Name:

Title:

Email Address:

Phone:

()-

Access Agreement

Access Agreement:

Form must be in PDF or Word format ONLY

Answer the question below:

= 5 - 5

Investigations

Director R.E. “Chip” Hawley

Services