Name of Form

Numbers of form

• Type

• Serial

Dimensions of form

• Height
• Width

Number of copies

Number of sheets

one side two sides

Number of lines

Number of check boxes

Ink color

Paper

• color
• weight
• texture

Typeface

Brand or printer

Union bug

Is the form pretty?

Agency issuing form

Size of agency
(number of employees)

Purpose of form

• for agency
• for me

How was form obtained?

• from a person at the agency
  • Agent's name
• by mail
  • requested unsolicited
• from a rack, dispenser or file
• another way

Where was form obtained?

• Street
• City State

When was form obtained?

• Hour
• Day Date

SHORT FORM FORM

refused by agency

waived by me

Are there requirements to

• receive this form?
• retain this form?

Number of spaces left blank or
marked 0, none, n.a., etc.

Number of redundancies
(same information required on different lines)

Time required to fill out form

Must be

• printed not written
• ink
• type written

• Fee $
• Oath Penalty
• Signature Witness

Which databases does the form information go to?

• issuing agency only
• unknown

Form filled out by

• Agent
• me
• not filled out

Was the form fun to fill out?

Other