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2. TO BE COMPLETED BY APPLICANT:
4. First Name*
5. Middle Name*
6. Last Name*
8. Address (Number, Street, City, State & Zip)
10. Phone Number
11. Place of Employment
13. Age
14. Date of Birth
15. SSN
17. Driver’s License Number
18. State
20. * List any Health Problems
22. Emergency Contact Name & Phone Number
24. Rquested Observation Date & Time

26.  

    Please fully complete this form. Your signature on the observation/confidentiality release form must be completed prior to submitting the form. Return this form to the Laramie/Albany County Records and Communications Center at least 3 days prior to the date requested for observation.

    Unless you are notified that your application to observe has been denied, you should report to the LARC Dispatch Center 5 minutes prior to the start time of your observation.

    Please read the confidentiality release agreement on the next page and have a full understanding before signing.

    * Required only for observation requests

28. Please select that which applies:

    1. I have requested that Laramie/Albany County Records and Communications (LARC) permit me to observe in Dispatch with a dispatcher who is on duty. My request is made for my benefit and is not for the benefit of the City of Laramie or LARC.
    2. I have requested admittance into LARC for reasons other than observation.
30. If you slected the second option for th equestion above, plese explain your reasons for requesting access.

    (ie. Equipment maintenance, visiting employee, custodial, etc.)

32. That during the course of the time I am in LARC there will be private and confidential information that I may see or hear that cannot be disseminated outside the criminal justice system.

    That during the course of the time I am in LARC there may be disclosed to me certain private and confidential information consisting of but not necessarily limited to:

    • Criminal Justice Information System (CJIS) data
    • National Crime Information Center (NCIC) data
    • Computer Aided Dispatch (CAD) data and history
    • Individual’s names, dates of birth, social security number, address and phone number
    • Information relating to in-progress, ongoing or “cold” crimes
    • Medical information

    That I shall not during, or at any time after my time in LARC use for myself or others, disclose or divulge to others, any such private or confidential information or any such information that I should reasonably consider to be private or confidential.

34. Date
    Date
35. Name
37. Please check this box and retype your name to certify you have signed this form.

    1. By typing my name in the box to the right, I certify I have signed this form.
38. Signature
40. Witness
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field