Access Request Form
ATTENTION: Before you begin completing this application form, you will need to have some required documentation completed and scanned so it can be attached to this form before it is submitted.  You will need a completed Access Agreement, completed regulations forms for each authorized official and if you are allowed access via NCGS 143B-932 - Specialized Populations, you will need proof of qualification.

All fields with BLUE labels are required
Agency Information  
Is this a new or renewal Access Agreement Request?:
NOTE: When you choose an Agency Main Type below, Sub Types will be shown for several selections.  For example, if you choose Health Care, you will then be given the following sub type options: Adult Care Home, Family Care Home, Home Care, Hospice, Hospital, Mental Health, Nursing Home, Nursing Pool.  
Mailing Address Same as Street Address?:
Information Storage  
Primary Contact  
()-
Secondary Contact  
()-
Billing Contact  
()-
Is billing address same as main address?:
Audit Contact  
()-
CJIS Online Administrator (CJIS Security Awareness Training Admin)  
()-
Statutory Authority  
If you do not know which statute to choose, contact DHHS for assistance.
We cannot advise you on which statute to choose.
 
 
List of Authorized Officials  
First Authorized Official  
()-
Second Authorized Official  
()-
Third Authorized Official  
()-
Access Agreement  
Form must be in PDF or Word format ONLY  
Is 6 > than 5? (true/false)