Background Check Form (PDF)

www.waterfordpolice.org 
Marc Balestracci 
Chief of Police 
WATERFORD POLICE DEPARTMENT 
41 AVERY LANE 
WATERFORD, CT 06385-2819 
(860) 442-9451 TEL
 mbalestracci@waterfordct.org 
Local Background Check Request Form 
Photo Identification Required 
Please Print 
Date of Request 
Name___________________________________________________________________________ 
Date of Birth (please format MM/DD/YEAR)_____________________________________________ 
Address__________________________________________________________ 
Maiden/Alias Names_________________________________________________ 
*Signature_________________________________________________________________
*By submitting this request, I certify that all information contained in this request is complete and
accurate.  I hereby further authorize the Waterford Police Department to conduct a local background
check using files pertaining to both traffic and criminal arrests under the listed name.
*I hereby release the Waterford Police Department, including its officers, employees, or related
personnel, both individually and collectively, from any and all liability for damages of whatever kind
which may result due to compliance with this authorization and request to release information.
o
I have read, understand and agree to the background check waiver.
o
I do not agree to the background check waiver.
Waterford Police Use Only 
Date of Incident 
Charge/s 
Disposition 
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