1

First Name:

 *

First Name:

2

Middle Name:

Middle Name:

3

Last Name:

 *

Last Name:

4

Nickname/AKA

Nickname/AKA

5

Type of Residence (Single family home, apartment, convalescent care, group home, etc.)

 *

Type of Residence (Single family home, apartment, convalescent care, group home, etc.)

6

Street Address:

 *

Street Address:

7

City:

 *

City:

8

State:

 *

State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

9

Zip Code:

 *

Zip Code:

10

Registrant's Home Phone:

Registrant's Home Phone:ext.

11

Registrant's Cell Phone:

Registrant's Cell Phone:ext.

12

E-mail for the responsible person completing this form:

 *

E-mail for the responsible person completing this form:

13

Previous Address:

Previous Address:

14

Second Previous Address:

Second Previous Address:

15

English Speaking

 *

English Speaking

Yes

No

16

Other languages spoken

Other languages spoken

17

Gender

 *

Gender

Male

Female

18

Height:

 *

Height:

19

Weight:

 *

Weight:

20

Hair Color:

 *

Hair Color:

Brown	Blonde
Red	Multi-colored
Gray	Silver
Black	Bald

21

Eye Color:

Eye Color:

Brown	Green
Blue	Black
Hazel	Gray

22

Date of Birth:

 *

Date of Birth:

23

Ethnicity:

 *

Ethnicity:

24

Skin Tone:

Skin Tone:

Light

Medium

Dark

25

Glasses:

Glasses:

Yes

No

Contacts

26

Hearing Aid:

Hearing Aid:

Yes

No

27

Scars:

Scars:

28

Tattoos:

Tattoos:

29

Other Identifying Marks:

Other Identifying Marks:

30

Does Registrant Drive

Does Registrant Drive

Yes

No

31

Driver's License / ST

Driver's License / ST

32

(Vehicle Information) License Plate #:

(Vehicle Information) License Plate #:

33

Vehicle Description (Year, Make, Model, Style, Color)

Vehicle Description (Year, Make, Model, Style, Color)

34

Clothing Style:

Clothing Style:

35

Places Registrant likes to frequent or may be found:

Places Registrant likes to frequent or may be found:

36

Notes (Specific Characteristics)

Notes (Specific Characteristics)

37

Additional information that may assist officers upon contacting the Registrant. (For example: startled easily by noise, doesn't like bright lights, doesn't like to be touched...)

Additional information that may assist officers upon contacting the Registrant. (For example: startled easily by noise, doesn't like bright lights, doesn't like to be touched...)

38

Emergency Contacts (Parents/Guardian should be listed first if registrant is a minor)

Emergency Contacts (Parents/Guardian should be listed first if registrant is a minor)

Name	Address	Phone	Relationship
Name	Address	Phone	Relationship
Name	Address	Phone	Relationship

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