36C26118R0214-075.pdf

Required Information for Fingerprinting Name:

(Last) (First) (Full Middle/IO/NMN)

SSN: Date of Birth:

MM/DD/YYYY

Male Female

Race: (Check One)

(A)

Chinese Indian Japanese Indonesian Filipino Asian Indian Korean Samoan Polynesian any other Pacific Islander

(B) Black

(I) American Indian Eskimo Alaskan Native Native Person w/Tribal Affiliation

(U) Undeterminable Race

(W) Caucasian Mexican Central or South American other Spanish Culture or Origin Cuban Puerto Rican

Eye Color: (Check One)

BLK Black HAZ Hazel BLU Blue MAR Maroon BRO Brown MUL Multicolored GRN Green PNK Pink GRY Gray XXX Unknown

Hair Color: (Check One)

BAL Bald PLE Purple BLK Black PNK Pink BLN Blond or Strawberry RED Red or Auburn BRO Brown SDY Sandy GRN Green WHI White GRY Gray or Partially Gray XXX Unknown ONG Orange

Height: Weight:

Place of Birth: City: State/Country (if not US):

If foreign born, Citizenship:

E-mail address:

Position Title: Department/Service:

Signature: Date:

Employer: EOD/Appt. Date:

Type of Employee:

Employee Resident/Intern Student Fee Basis Temporary Employee Vet Canteen Svc Volunteer Contractor Without Compensation

Reason for Fingerprints: SAC NACI MBI BI PIV

Person taking fingerprints: Date:

SON: 1685 SOI: VAP9 IPAC#: 36001200

VA Sierra Nevada Health Care System, 975 Kirman Avenue, Reno, NV 89502-0993 (775) 829-5664/5665