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2. APPLICANT INFORMATION:
4. First Name
5. Last Name
7. Date of Birth
   (yyyy/mm/dd)
8. Gender
   -- Select One --MaleFemale
9. Hair Color
   -- Select One --BaldBlackBlond or strawberryBlueBrownGray or partially grayGreenOrangePinkPurpleRed or AuburnSandyWhiteUnknown or completely bald
11. Height
    (feet/inches - example 6' 3")
12. Weight
    (lbs.)
13. Eye Color
    -- Select One --BlackBrownGreenMaroonPinkBlueGrayHazelMulticoloredUnknown
15. Race

    1. Black
    2. White

    1. Asian/Pacific Islander
    2. Native American

    1. Other
17. Place of Birth
    (State or Country)
18. Citizenship
    (Country)
20. Home Address
22. City
23. State
24. Zip
26. Daytime Phone
    (xxx-xxx-xxxx)
27. Evening Phone
    (xxx-xxx-xxxx)
29. Driver's License
    (2-letter State Code (space) following all numbers and letters no dashes)
31. Reason Fingerprinted (select one):

    1. Adult Dependent Care
    2. Attorney/Client
    3. Child Care
    4. Criminal Justice
    5. Gold Seal/Adoption

    1. Gold Seal/Letter/Visa
    2. Government Employment
    3. Government Licensing or Certification
    4. Immigration/Visa
    5. Individual Challenge

    1. Individual Review
    2. MSP Licensing
    3. Private Party Petition
    4. Public Housing
33. Authorization Number
35. Mail Response to:
    (Mail option only available for Visa Gold Seal and/or Individual Review)
37. First Name
38. Last Name
40. Address
42. City, State, Zip
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

* indicates a required field