Form 1-783 Applicant Information

1-783 (Rev. 04-02-14)

OMB-1110-0052

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 criminal 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 uses. Under the Paperwork Reduction Act, you are not required to complete this form
unless it contains a valid OMB control number. The form takes approximately 3 minutes to complete.

Applicant Information * Denotes Required Fields
*Last Name

*First Name

Middle Name 1

Middle Name 2

*Date of Birth:

*Place of Birth:

*Country of Citizenship:

Country of Residence:

U.S. Citizen or Legal Permanent Resident:
Yes
No
Prisoner Number (if applicable):

*Last Four Digits of Social Security Number:
*Height:

*Weight:

*Hair (please check appropriate box):
Bald

Black

Purple

Blonde/Strawberry

Red/Auburn

Sandy

Blue

Brown

Unknown

Gray

Green

Orange

Pink

White

*Eyes (please check appropriate box):
Black

Blue

Brown

Gray

Green

Hazel

Maroon

Multicolored

Pink

Unknown

Applicant Home Address
*Address
*City
*Postal (Zip) Code
Phone Number

*State
*Country
E-Mail

Mail Results to Address
C/O
Address

ATTN

State
Country

City
Postal (Zip) Code
Phone Number (if different from above)
Payment Enclosed: (please check appropriate box)
CERTIFIED CHECK
Reason for Request:
Personal review
International adoption

MONEY ORDER

CREDIT CARD FORM

Challenge information on your record
Live, work, or travel in a foreign country

Adoption of a child in the U.S.
Other____________________

* APPLICANT SIGNATURE______________________________________________

DATE________________

Mail the signed applicant information form, fingerprint card, and payment of $18 U.S. dollars to the following address:
FBI CJIS Division – Summary Request
1000 Custer Hollow Road
Clarksburg, West Virginia 26306
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.