Last Name

First Name

Middle Name

Date of Birth

Last 4 digits of SSN

Place of Birth

Street Address

City

State

Postal Code

Country

Phone Number

U.S. Citizen or LPR of U.S.

Country of Citizenship

Country of Residence

Email notification

US Mail

Email (for FBI report)

Applicant/Applicant's Attorney

Results Street Address

Results City

Results State

Results Postal Code

Results Phone

Credit Card

Debit Card

Business Check

Cashier's Check/Money Order

Cash

Reason for Request

Applicant Signature (typed)

Date