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Regulatory and Investigative Agent Partner Registration Form

APPLICANT INFORMATION
First Name:*

Last Name:*

Agency / Organization Name:*

Agency Type:*
City County State Federal

Address:*

Address 2:

City:*
State: (ie: MO)* 
  Zip code:*
County:*
 

CONTACT INFORMATION
Phone: (e.g. ###-###-#### x Ext.)*

Mobile Phone: (e.g. ###-###-####)
 
E-mail:* (if applicable use your Agency email address)
 

WEBSITE ACCESS
Create a Password:*

Please include alpha and numeric
characters in your password.

SUPERVISOR INFORMATION
Immediate Supervisor*

Title
*

Daytime Phone*

E-mail Address (if available)

Any Questions? Contact RCIU - Phone: 1-888-484-8477  or  ruralcrimes@mshp.dps.mo.gov


Providing false or misleading information is a violation of Federal Law and may be subject to prosecution under Title 18 USC 1001.