1-783 (Rev. 5-5-2011)
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
Last Four Digits of Social Security Number
Applicant Home Address
*Address
*City
*State
*Postal (Zip) Code
*Country
Phone Number
E-Mail
U.S. Citizen or Legal Permanent Resident
Yes
No
Country of Citizenship:
Country of Residence:
Mail Results to Address
C/O
ATTN
Address
City
State
Postal (Zip) Code
Country
Phone Number (if different from above)
Payment Enclosed (please check appropriate box)
CASHIER’S CHECK
MONEY ORDER
CREDIT CARD FORM
Number of Copies
X $18 per Copy = Total Payment of $
Enclosed
Reason for Request
*APPLICANT SIGNATURE
DATE
You may request a copy of your own identification record to review it or obtain a change, correction, or an
update to the record.