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