BACKGROUND STUDY DATA COLLECTION FORM
Please note that all of the following information (unless otherwise indicated) is required by
the Bureau of Criminal Apprehension (BCA) or Federal Bureau of Investigations (FBI).
* Indicates that the field is optional.
First Name
Full Middle Name
Last Name
Suffix
□ Junior □ Senior
□ Third
□ Fourth
Permanent/Physical Street Address
City
State
Zip Code
* County
Mailing Address (if different from physical address)
□ Same as Permanent Address
Prior Names and Aliases, including maiden names, married names, name changes, and any
name you have used or been known by. These are required for the background study to be
valid and are required by law.
□ I have not been known by any other names.
* Social Security Number
Date of Birth
(Providing your SSN will allow
this study to be transferred to
other agencies if you seek
employment or volunteer work
elsewhere.)
Race
□ Asian or Pacific Islander
□ African American
□ Native American
□ White
□ Unknown/Other
Sex
□ Male
□ Unknown
Height
Weight
Place of Birth
*Phone
Hair Color
□ Bald □ Black
□ Blond/Strawberry □ Brown
□ Gray or Partially Gray
□ Red or Auburn □ Sandy
□ White □ Blue □ Green
□ Orange □ Pink □ Purple
□ Unknown
* US Citizen?
□ Yes □ No
* Phone Type
*Secondary Phone
* Secondary Phone Type
* Email
□ Female
□ Other
Eye Color
□ Black □ Blue □ Brown
□ Gray □ Green □ Hazel
□ Maroon □ Multicolored
□ Pink □ Unknown
Prior Addresses (if you have lived out of state in the past 5 years)
□ I have not lived out of state during the past 5 years.
City
State
Year From/Year To
City
State
Year From/Year To
City
State
Year From/Year To
City
State
Year From/Year To
City
State
Year From/Year To
Document:
□ State issued driver's license
□ State issued identification
card
□ US Armed Forces ID
□ Passport
□ Visa
□ Other
Issuing State/Authority:
Document #:
Expiration Date: