Case #
Statement of (print full name):
Date of Birth and Social Security #:
Drivers License # and State of Issue:
Residence Address:
Mailing Address:
Contact Phone Number(s):
Statement: Continue Statement on Back
Signed: Date: Time:
Continue Statement on Back
University of Alaska Fairbanks
Police Department
PO Box 755560 1788 Yukon Drive
Fairbanks Alaska 99775
(907)474-7721 Fax (907) 474-5555
UA is an AA/EO employer and educational institution and
prohibits illegal discrimination against any individual:
Statement Continued
Signed: Date: Time: