REQUEST FOR LIVE SCAN SERVICE
Applicant Information:
Name
First Name
Middle Initial
Last Name
Suffix
Other Name: (AKA or Alias)
First Name
Middle Initial
Last Name
Suffix
Sex
Male
Female
Nonbinary/Unspecified
Height
Weight
Eye Color
Hair Color
Place of Birth (State or Country)
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.
Date
-
Month
-
Day
Year
Date
Applicant Signature
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