CTMD Form 1-4 "Police Record Check" - Connecticut

What Is CTMD Form 1-4?

This is a legal form that was released by the Connecticut Military Department - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2013;
  • The latest edition provided by the Connecticut Military Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of CTMD Form 1-4 by clicking the link below or browse more documents and templates provided by the Connecticut Military Department.

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Download CTMD Form 1-4 "Police Record Check" - Connecticut

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CTMD Form 1-4
(Rev. 11/2013)
CONNECTICUT MILITARY DEPARTMENT
POLICE RECORD CHECK
PURPOSE: To determine eligibility of a prospective enlistee into the Armed Forces of the State of
Connecticut
AUTHORITY: Connecticut General Statutes Section 27-2, 27-6a, 27-7, 27-8, 27-56, 27-57, 27-58,
29-11, Connecticut Regulation 601-202
INSTRUCTIONS: The applicant will complete all sections correctly and accurately to the best of their
knowledge. An officer in the command will sign the form as the person and unit making the request.
The individual will sign their consent to release the files. Failure to consent to the release of the files
may result in dismissal from Armed Forces of the State of Connecticut.
The unit will forward the completed document to the Department of Public Safety – Bureau of
Identification. Once the document is returned to the Connecticut Military Department, a copy will be
maintained in the individual’s records.
SEND COPIES OF APPLICATIONS & SUPPORTING DOCUMENTATION TO:
Connecticut Military Department
Military Administrative Officer
360 Broad Street Room #113
Hartford, Connecticut, 06105-3706
(860) 493-2721 (fax)
Page 1 of 2
CTMD Form 1-4
(Rev. 11/2013)
CONNECTICUT MILITARY DEPARTMENT
POLICE RECORD CHECK
PURPOSE: To determine eligibility of a prospective enlistee into the Armed Forces of the State of
Connecticut
AUTHORITY: Connecticut General Statutes Section 27-2, 27-6a, 27-7, 27-8, 27-56, 27-57, 27-58,
29-11, Connecticut Regulation 601-202
INSTRUCTIONS: The applicant will complete all sections correctly and accurately to the best of their
knowledge. An officer in the command will sign the form as the person and unit making the request.
The individual will sign their consent to release the files. Failure to consent to the release of the files
may result in dismissal from Armed Forces of the State of Connecticut.
The unit will forward the completed document to the Department of Public Safety – Bureau of
Identification. Once the document is returned to the Connecticut Military Department, a copy will be
maintained in the individual’s records.
SEND COPIES OF APPLICATIONS & SUPPORTING DOCUMENTATION TO:
Connecticut Military Department
Military Administrative Officer
360 Broad Street Room #113
Hartford, Connecticut, 06105-3706
(860) 493-2721 (fax)
Page 1 of 2
CTMD Form 1-4
(Rev 11/2013)
CONNECTICUT MILITARY DEPARTMENT
POLICE RECORD CHECK
APPLICANT INFORMATION
Last Name
First Name
Middle Initial
Home Address (No PO Boxes)
City
State
Zip Code
Dates at this
From:
To:
Residence:
Date of Birth
Place of Birth (City/State)
Social Security Number
Racial Category:
American Indian/Alaska Native
White
Asian
Native Hawaiian or Pacific Islander
Black or African American
Hispanic or Latino
Person & Unit Making this Request:
Name (Last, First, MI)
Rank
Title
Signature
PRIVACY ACT STATEMENT
The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with state law
and regulations. Making a knowing and willful false statement on this form may be punishable under the Connecticut
Code of Military Justice. All information provided by you, which possibly may reflect adversely on your past conduct and
performance, may have an adverse impact on you in your career in the Armed Forces of the State of Connecticut and in
situations such as consideration for special assignment, security clearances, court martial and administrative proceedings.
I HEREBY CONSENT TO RELEASE FROM YOUR FILES
Signature
THE INFORMATION REQUESTED BELOW:
TO BE COMPLETED BY POLICE OR JUVENILE AGENCY
The person described above who claims to have resided at the address shown above, has applied for enlistment in the
Armed Forces of the State of Connecticut. Please furnish from your files the information relative to the section below.
Has the applicant a police or juvenile record, to include minor traffic violations?
YES
NO
(If YES, what was the offense or charge, date, disposition and sentence?)
Is the applicant now undergoing court action of any kind? (If YES, provide details)
YES
NO
This is to certify that the above data as corrected are true and correct according to the record on file in this office. This
information is confidential and cannot be used in any other manner except for official purposes
MAIL TO:
Return Document To:
State of Connecticut – Department of Public Safety
State of Connecticut – Military Department
Division of State Police – Bureau of Identification
Governor William A. O’Neill Armory
1111 Country Club Road
360 Broad Street – Room #113
Middletown, CT 06457-2389
Hartford, CT 06105-3780
(860) 685-8480 – phone
(860) 524-4968 – phone
(860) 685-8361 – fax
(860) 493-2721 – fax
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