EFTA00109759

FEDERAL BUREAU OF PRISONS

CDFRM

<table border="1"><tr><td colspan="4">ARRESTING OFFICER WILL COMPLETE ALL REQUIRED DATA ON THIS FORM PRIOR TO COMMITTING TO MCC/MDCs.</td><td colspan="3">Register Number</td><td rowspan="3">PICTURE</td></tr><tr><td colspan="2">Name: Last</td><td colspan="2">First</td><td colspan="3">Middle</td></tr><tr><td colspan="7">AKAs:</td></tr><tr><td>Race(Check)
B W A I</td><td>Sex(Check)
M F</td><td colspan="2">Ethnic Origin(Check)
Hispanic or Other</td><td>D.O.B.</td><td colspan="2">SSN:</td><td>FBI:
INS:
Other:</td></tr></table>

<table><thead><tr><th>CHECK</th><th>CATEGORY OF CHARGES(S):</th></tr></thead><tbody><tr><td>___</td><td>FELONY ___ MISDEMEANOR</td></tr></tbody></table>

# Date of Offense: ___ Date of Arrest: ___ Place of Arrest:

| State of Birth | Country of Birth | Citizenship | Current Address | Zip Code |
| :--- | :--- | :--- | :--- | :--- |
| Height Ft: In: | Weight | Hair | Eyes | Scars / Marks / Tattoos |
| Injuries / Medication | | | | Emergency Contact: (Name, Address, Phone Number) |

| Arrained Y | Sentenced N | Special Handling: _Y or _N |
| :--- | :--- | :--- |
| IN | IN | IN |
| Remanding Official (Name) Sign Print | | Agency/District | Phone/24 Hour Number |
| OUT | OUT | OUT |
| Removing Official (Name) Sign Print | | Agency/District | Phone/24 Hour Number |

## FOR BOP USE ONLY

### Receiving Official (Name) Sign Print

Date / Time Sign Print

Releasing Official (Name) Date / Time Print

### Sentry Load Data: (Must Initial) Name Search Completed by:

**Clearance/Separate Checked by:**
[OPTIONAL USE]
ARS Code
Add AKA’s
Create Cash Account
Design Cash Account
Detainers
Court
Clothing Bag #

RIGHT THUMBPRINT

Original-for ISM as Remanding-Removal receipt; Copy-for Control as Removal Receipt (NCIC); Copy-For Removing Official; Copy-for Control as Remanding Receipt (Inmate); Copy-INS-Alien in Custody.

(This form may be replicated via WP) This form replaces BP-S377(58) and BP-377(58) of JUL 91