FBI CRIMINAL REPORT REQUEST
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.
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
* U.S. Citizen or Legal Permanent Resident Yes No (If no, you must make your request directly with the FBI)
Country of Citizenship Country of Residence
* Phone Number
* Email Address
Mail Results to This Address (Attorney Only)
C/O ATTN
Address
City State
Postal (zip) code Country
Phone Number (if different from above)
* FBI Criminal Report Includes one copy * Shipping Options Please check one box
* Shipping Select one Shipping Option $
* Additional Copies
@ $9.00 each $
Quantity
USPS First Class Mail No charge
USPS Priority Mail (2-3 Day Delivery) $14.00
FedEx (Overnight Delivery) $40.00
* Total Payment Enclosed $
* Payment Type Please check one box
Cashier’s Check Money Order Credit Card (Include Credit Card Authorization form)
* Personal Review/Correction Work Visa/Student Visa Foreign Residency/Travel Reason for my request
Must check one box Adoption Attorney Request Other (please specify)
* APPLICANT SIGNATURE * DATE
* Signed Criminal Background Check Disclaimer must be included with order. You may request a copy of your own
identification record to review it or obtain a change, correction, or an update to the record.
MFR-CRR-1809
$
**
Apt#
**Pricing does include fingerprint rolling fees for mailing ink cards, or live scan fees for electronic submissions.
85.00
NATIONAL CREDIT REPORTING
0.00
0.00
85.00
CLEAR FORM
FBI Criminal Report Request
CriminalBackgroundCheckDisclaimer
I declare under penalty of perjury under the laws of the United States of America that the enclosed fingerprint
impression is that of the person completing this form, and that all of the information submitted on the FBI
Criminal Report Request form is true and correct.
Applicant acknowledges that information sent through electronic mail, United States Mail, and courier service is
not secure. Applicant further acknowledges that NCR may not alter any of the information contained in the FBI
report, even if there are obvious errors. Applicant waives, disclaims, and holds NCR harmless from and
against any inadvertent disclosure of Applicant's FBI report and from any inaccuracies contained within said
FBI report, provided that nothing herein affects any intentional, wrongful disclosure of Applicant's FBI report or
the contents thereof.
Applicants Name
Signature
Date
MFRMC1809
NATIONAL CREDIT REPORTING
CLEAR FORM
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