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2. COLLECT File 10- Identity Theft Entry Form
4. By completing and signing this form, I am giving my consent to be entered as a File 10*

   1. I consent to having my personal information entered as a File 10 in COLLECT
6. GPD Call For Service Number*
   You need to be a victim of an Identity Theft. Please provide your case number. If you do not have your case number, complete the Online ID Theft complaint form and when assigned a case number re-apply for the FIle 10. If you were assigned a case number, but forgot it, please call 203-622-8024 for assistance in retreiving your case number.
7. Date of ID Theft*
   mm-dd-yyyy-
9. Password*
   Important- DO NOT FORGET PASSWORD. A password can be anything you wish.
10. Identity Theft Type*
    -- Select One --Check or Savings AccountCredit Card or Credit LineGovernment Documents or BenefitsInternet or EmailLoansPhone or other UtilitiesSecurities or other InformationOther
12. First and Middle Name*
13. Last Name*
15. Date of Birth*
    MM-DD-YYYY
16. Gender*
18. Race*
19. Hispanic*
    Yes or No
20. Height*
    Feet -Inches
22. Weight*
    Lbs
23. Hair color*
25. Eye Color*
26. Skin Tone*
28. Markings, Tattoos, etc*
29. State or Country of Birth*
31. SSN*
    XXX-XX-XXXX
33. Operator's License Number*
35. License State*
36. Year License Expires*
38. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
40. Electronic Signature
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field