Record Restriction Form
"
*
" indicates required fields
Your Name
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First
Last
Maiden Name/Alias (at time of arrest)
Date of Birth
*
MM slash DD slash YYYY
Race
*
Select One
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or More Races
No Response
Gender
*
Select One
Male
Female
Non-binary
Agender
My gender is not listed
Prefer not to answer
Social Security No.
*
Address
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Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Email Address
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Phone
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Upload Your License/ID
*
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 25 MB.
Arresting Agency
Date of Arrest
MM slash DD slash YYYY
Record Restriction Consent
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I request the arrest record information described above pertaining to me be restricted from the record(s) of the arresting agency pursuant to the provisions of O.C.G.A. 35-3-37(d).
GBI/GCIC Consent
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I hereby give my consent for the Office of the Fulton County Solicitor General to receive any Georgia criminal history record information pertaining to me, as authorized under state and federal law for individuals with a criminal justice agency. I also understand that I may be contacted by someone from the Georgia Justice Project to discuss available options depending on my record.
Signature
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