Get I-783 2011

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 Date of Birth Last Four Digits of Social Security Number Applicant Home Address Address City Postal Zip Code Country State Phone Number E-Mail U*S* Citizen or Legal Permanent Resident Country of Citizenship Mail Results to Address C/O Yes ATTN Payment Enclosed please check appropriate box CASHIER S CHECK MONEY ORDER Number of Copies No Country of Residence CREDIT CARD FORM 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. 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. 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. 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. 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 Date of Birth Last Four Digits of Social Security Number Applicant Home Address Address City Postal Zip Code Country State Phone Number E-Mail U*S* Citizen or Legal Permanent Resident Country of Citizenship Mail Results to Address C/O Yes ATTN Payment Enclosed please check appropriate box CASHIER S CHECK MONEY ORDER Number of Copies No Country of Residence CREDIT CARD FORM 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. .