Form Instructions

The Virginia Department of Health’s Office of Emergency Medical Services
requires all EMS providers in the Commonwealth to have a Criminal History Record on file.

**Complete only the NAME TO BE SEARCHED field. Highlighted in YELLOW on the document.

The Town of Chilhowie’s Fleet Safety Program requires anyone driving Town vehicles to have a driving record check performed every year.

**Complete only the SUBJECT’S PERSONAL INFORMATION and the SUBJECT’S
DRIVING INFORMATION sections, including signature and date.

Return BOTH forms with your COMPLETED application.