Federal Bureau of Investigation
Criminal Justice Information Services Division
1000 Custer Hollow Road
Clarksburg, WV 26306

RE: CRIMINAL BACKGROUND CHECK

I am requesting this background check and report for a personal review. Enclosed is the required, completed fingerprint card,
along with the $18 processing fee. (Certified check or money order, payable to: Treasury of the United States).

PLEASE RETURN THE REPORT TO ME AT THE FOLLOWING ADDRESS:

Printed or Typed:

                           ___________________________________________________________
                           Full Legal Name

                           ___________________________________________________________
                           Street Address

                           ___________________________________________________________  
                           City, State, Zip Code

                                                                             _____________________________________
                                                                                                             Signature

                                                                             _____________________________________
                                                                                                                Date