[Name or town or city] Privacy Act Requirements
Notifications to Applicants required to have a National Fingerprint Record-Check
 
Authorized governmental agencies that conduct a national fingerprint-based criminal history record check on an applicant for a noncriminal justice purpose are obligated to ensure the applicant is provided certain notices and other information. This document complies with such requirements.
The applicant is hereby notified:

• Your fingerprints will be used to check your criminal history records.
• You have received, and your signature below acknowledges, the attached Privacy Act Statement, which is dated 3/30/2018.
• You have the opportunity, within 10 days, to challenge in writing the accuracy of the information in the record.
  • Corrections to the record must be made within 60 days of the date of this notification, and you will not be denied a license based on information in the record until such 60 days has passed, unless you decline to make corrections.
  • Procedures for obtaining a change, correction, or update of a criminal history record are set forth in 28 CFR 16.34.
• The [City/Town of …] will use the record solely for the purpose of ________________ (specify liquor license, beer license, taxi cab license, dispatcher, etc.).
• The [City/Town of …] will not disseminate the record outside the receiving department.

 
 
As the undersigned I have read and understand the notifications described above. I have also received a copy of the Federal Privacy Act Statement.
 
___________________________________________________________                               _________________
                                             Signature of Applicant                                                                               Date