Applicant information form

PRIVACY ACT STATEMENT

The FBI’s acquisition, retention, and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16.30-16.34. The purpose for requesting this information from you is to provide the FBI with a minimum of identifying data to permit an accurate and timely search of identity history identification records. Providing this information (including your Social Security Account Number) is voluntary; however, failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent pursuant to the Privacy Act of 1974 and all applicable routine issues.

APPLICANT INFORMATION (*DENOTES REQUIRED FIELD)

ORI Number:

Last Name:

First Name:

Middle Name:

Date of Birth:

Social Security Number:

Place of Birth:

Driver’s License:

Address:

City:

State:

Postal Code:

Phone Number

Email:

US Citizen or Lawful Permanent Resident Alien of the US:

Yes No

Country of Citizenship:

Country of Residence:

Height

Weight:

Hair Color:

Eye Color:

Sex:

Race

Reason for Request:

APPLICANT SIGNATURE

You may request a copy of your own Identity History Summary to review it or obtain a change, correction, or an update to the summary.

Date

APPLICANT INFORMATION FORM

PRIVACY ACT STATEMENT

APPLICANT INFORMATION (*DENOTES REQUIRED FIELD)

Secure Your Spot Today! Book an Appointment Now! or Call 833-825-5885

Secure Your Spot Today!
Book an Appointment Now!
or Call 833-825-5885