LEAVE THIS SPACE BLANK |TYPE OR PRINT |SEX |RACE | | | |LAST NAME FIRST NAME MIDDLE NAME|--------|----- | |HT. |WT. | |(Inches)| | | | |----------------------------------|--------|----- |CONTRIBUTOR AND |ALIASES |HAIR |EYES |ADDRESS | | | | | |-------------- -------------------------| | |DATE OF BIRTH SIGNATURE OF PERSON | | | FINGERPRINTED | | |-------------- | | |PLACE OF BIRTH | | | |------------------------------------------------- -------------------------|YOUR NUMBER |LEAVE THIS SPACE BLANK SCARS AND |AMPUTATION | | MARKS | |------------------|CLASS | |PLACE FBI NUMBER | ------------------------- -------------------------|HERE | SIGNATURE OF DATE |------------------|REF. OFFICIAL TAKING | _ CHECK IF NO | -------------------------- FINGERPRINTS ||_| REPLY | | IS DESIRED | --------------------------------------------------------------------------- 1. RIGHT THUMB|2. RIGHT INDEX|3. RIGHT |4. RIGHT RING |5. RIGHT | | MIDDLE | | LITTLE | | | | --------------------------------------------------------------------------- | | | | --------------------------------------------------------------------------- 1. LEFT THUMB |2. LEFT INDEX |3. LEFT MIDDLE|4. LEFT RING |5. LEFT LITTLE | | | | | | | | --------------------------------------------------------------------------- | | | | --------------------------------------------------------------------------- LEFT FOUR FINGERS TAKEN |LEFT |RIGHT |RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY |THUMB |THUMB |SIMULTANEOUSLY | | | | | | | | | | | |