You are about to request access to a secure site. Information that you enter on this page will be investigated for authenticity and accuracy. If you are not an employee of an ORI number-defined agency, please do not complete this request form.
New User Registration for Incident Based Reporting
Only register for this site if your agency is reporting or planning to report Incident Based crime.
If your agency is reporting Summary based, do not register here.


NOTE: The fields indicated with an asterisk (*) below are required to complete this form
Agency Information:
*Agency ORI:
*Address:
*City:
*State:
*Zip Code    
User Information:
*First Name:
Middle Name:
*Last Name:
Suffix:
*Last Four SSN:
*Date Of Birth (MM/DD/YYYY):
Title:
*Phone    
Phone Ext
*E-Mail:
*Repeat E-Mail:
Fax:
MIBRS Information:
*Access Level:
*If you are an agency employee, will you be the primary person submitting crime data?
*Enter Password:
*Re-enter Password:
  Note: This is the password you will use to access MIBRS.
Passwords must be between 6 and 15 characters in length, cannot contain spaces, and must contain at least one upper case character, lower case character, number, and at least one of the following special characters !@#$%^&*()+=

The first character must be an upper case character, lower case character or number.