Form Center

2. First Name
3. Last Name
5. Address
7. City
8. State
9. ZIP Code
11. Phone Number
12. Email Address
14. Date of Birth
    Date of Birth
15. Race
16. Sex
18. Social Security Number
19. Drivers License Number
21. Reason for request
23. Requestor information:
25. Requestor First Name
26. Requestor Last Name
28. Address
30. City
31. State
32. ZIP Code
34. Phone Number
35. Email Address
37. Agency information:
39. Agency Name
41. Agency Address
43. City
44. State
45. ZIP Code
47. Agency Phone Number

49. The record you will receive is NOT A CERTIFIED Arrest Record. You will only receive a record of those arrests that are maintained by the Winston-Salem Police Department. For employment or other such purposes you should obtain a CERTIFIED Arrest Record available from the Forsyth County Clerk of Court. 

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field