AUTHORITY FOR RELEASE OF INFORMATION

State and Federal Record Check

I authorize the North Carolina Department of Justice through the State Bureau of Investigation, Division of

Support Services to perform a fingerprint search of the State’s criminal history record file and a

fingerprint search of the Federal Bureau of Investigation’s files for a national criminal history record check

in connection with my application for a medical license with the North Carolina Medical Board pursuant to

N.C.G.S. 90-11(HB 1638).

Please print or type the following information:

Name:

Last First Middle Maiden

Soc Sec #: Date of Birth:

Sex: Race:

I understand that the North Carolina State Bureau of Investigation, Division of Support Services, and its

officials and employees shall not be held legally accountable in any way for providing this information to

the North Carolina Medical Board, and I hereby release said agency and persons from any and all liability

which may be incurred as a result of furnishing such information. I further understand that the North

Carolina Medical Board cannot provide a hard copy of the results of this criminal history record check to

me.

Applicant’s Signature:

_____________________________________

Date:

_____________________________________

ORI # BOME00000 - NORTH CAROLINA MEDICAL BOARD

01-132-10

North Carolina Medical Board