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:____________________________
Birth Date:_______________________
Social Security #:___________
Additional Information:________________________________________________
_____________________________________________________________________________
Signature ________________________________________________________
Date _____________
KBI RESPONSE:
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