CAPITAL CITY GUN CLUB, INC.

P.O. Box 332, Topeka, KS 66601-0332

102KS3152

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby request and authorize the Kansas Bureau of Investigation to furnish the above named company with criminal history information as described in K.S.A. 1985 Supp. 22-4701(b). This includes all information defined with K.A.R. 10-1-1 (b), (c), and (d).

I voluntarily waive all right of recourse and release you from liability for compliance with this authorization.

Last ___________________________________________________________
First __________________________________________________________
Middle _______________________________________________________
Any other name used: _______________________________________

Street ________________________________________________________
City__________________________________________________________
State_________________________________________________________
Zip Code ______________________________________________________

Sex:__________ Race:__________Height:__________Weight:__________
Place of Birth:________________________________
Birth Date: (mm/dd/yyyy) ______________________
Social Security #:______________________________
Occupation:__________________________________

Additional Information:___________________________________________________
_________________________________________________________________________

Signature __________________________________________________________
Date: (mm/dd/yyyy) __________________________ 

KBI RESPONSE: