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ATTN: RECORDS / DEPARTMENT
OF PUBLIC SAFETY / PO BOX 1628 / SANTA FE, NM 87504-1628
$7.00 PER RECORD CHECK AUTHORIZATION FOR RELEASE OF INFORMATION I,_____________________________________________________________________
PURSUANT TO NMSA 1978, SECTION 29-10-6(A) (Repl. Pamp. 1990), OF THE NEW MEXICO ARREST RECORD INFORMATION ACT, HEREBY APPOINT: _______________________________________________________________________
AS AN AUTHORIZED AGENT FOR ME FOR THE PURPOSE OF INSPECTING (AND / OR OBTAINING COPIES) ANY NEW MEXICO ARREST FINGERPRINT CARD SUPPORTED RECORD INFORMAITON MAINTAINED BY THE DEPARTMENT OF PUBLIC SAFETY, INCLUDING INFORMATION CONCERNING FELONY OR MISDEMEANOR ARRESTS. TO THE CUSTODIAN OF THE RECORDS IN QUESTION, I HEREBY DIRECT YOU TO RELEASE SUCH INFORMATION TO THE AUTHORIZED AGENT AS DESCRIBED ABOVE. I HEREBY RELEASE THE CUSTODIAN OR CUSTODIANS
OF SUCH RECORDS AND THE DEPARTMENT OF PUBLIC SAFETY, INCLUDING ANY OF
THEIR AGENTS, EMPLOYEES, OR REPRESENTATIVES IN ANY CAPACITY, FROM ANY
AND ALL CLAIMS OF LIABILITY OR DAMAGE OF WHATEVER KIND OR NATURE, WHICH
AT ANY TIME COULD RESULT TO ME, MY HEIRS, ASSIGNS, ASSOCIATES, PERSONAL
REPRESENTATIVE OR REPRESENTATIVES OF ANY NATURE BECAUSE OF COMPLIANCE BY
SAID CUSTODIAN OR CUSTODIANS WITH THIS "AUTHORIZATION FOR RELEASE OF INFORMATION"
AND MY REQUEST CONTAINED HEREIN FOR THIS RELEASE OR BECAUSE OF ANY USE OF
THESE RECORDS. THIS RELEASE IS BINDING, NOW AND IN THE FUTURE, ON MY
HEIRS, ASSIGNS, ASSOCIATES, PERSONAL REPRESENTATIVE OR REPRESENTATIVES OF
ANY NATURE.
SIGNATURE: ______________________________________
DATE: ______________________________________
(ATTN: NOTARY-ENSURE DOCUMENT IS SIGNED IN YOUR PRESENCE AND NAME, DOB, SSN INFO IS VERIFIED WITH A VALID ID) SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ____________, 20________. (SEAL) _________________________________________________
( NOTARY PUBLIC)
MY COMISSION EXPIRES: __________________________
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