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A Caring Hand
Beehive Homes
CCSD Staff
CCSD Volunteers
City Business License
Comfort Hospice
Critical Nurse Staff
Danville Services
Deep Roots - Employee/Vendor
Deep Roots - Owner/Agent
Fingerprint Card
Gaming Control
Highland Manor
Kindred at Home
Mesa Valley Estates
Mesa View Home Care
Mesa View Hospice
Mesa View Hospice Volunteer
Mesa View Hospital
NV Department of Education
NV Real Estate Division
NV State Board of Nursing
NV State Contractors Board
NV State Division of Insurance
Omnia Homecare
Omnia Hospice
Other
Virgin Valley Home Care
Other reason
Name
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Physical Address
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Drivers License Number
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Invalid numeric value.
State
*
Form field State has
Invalid alphabetic value.
Cell phone number
*
Phone
form field Cell phone number
must be in the format: (000) 000-0000
Social Security Number
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Email Address
*
Email
form field Email Address
is not in correct form
Date of Birth
*
Race
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Asian
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Unknown
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Not Hispanic or Latino
Unknown
Sex
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Gender Reported as Female
Gender Reported as Male
Other
Height
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Weight
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Eye Color
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Black
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Green
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Hair Color
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Bald
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Brown
Gold
Green
Gray
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Birth City
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Form field Birth City has
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Place of Birth
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Albania
Alberta (Canadian Province)
Africa
Andorra
Anguilla
Afghanistan
Aguascalientes (Mexican State)
Ashmore/Cartier Islands
Antigua and Barbuda
Aruba
Alaska
Alabama
American Samoa (Islands)
Algeria
Angola
Armenia
Azores (Islands)
Arkansas
Australia
Argentina
Austria
Azerbaijan
St Kitts/Nevis/Anguilla
Apache Tribe
Antarctica
Arizona
Baja California (Northern Section) ( Mexican State)
Barbados
British Columbia (Canadian Province)
Bahamas, The
Bahrain/Bahrain
Bassas Da India
Belgium
Belize (Formerly British Honduras)
Burundi
Baja California (Southern Section) ( Mexican State)
Baker Island
Bangladesh
Bermuda
Bhutan
British Indian Ocean Territory
Bosnia
Bouvet Island
Burma
British Solomon Islands (Now Solomon Islands)
Botswana
Bulgaria
Bolivia
Balearic Islands
Brunei
Belarus
Brazil
California
Columbia
Cuba
Canada ( Province Unknown)
Campeche (Mexican State)
Chad
Carolina Islands
Chihuahua (Mexican Border State)
Chiapas (Mexican State)
Cambodia (Formerly Khmer Republic and Kampuchea)
Czechoslovakia
Colima (Mexican State)
Cameroon
China
Colorado
Cayman Islands
Chile
Costa Rica
Cyprus
Connecticut
Coahuila (Mexican State)
Cape Verde Islands
Central African Republic
Congo
Ceylon (Now Sri Lanka)
Canal Zone
Cheyenne & Arapaho Tribes
Clipperton Island
District of Columbia
Cocos (keeling) Islands
Delaware
Distrito Federal (Mexico D.F.)
Comoros, Fed Islamic Rep
Benin (Formerly Dahomey)
Cook Islands
Coral Sea Islands
Denmark Devils Lake Sioux Tribe
Dominica
Djibouti
Durango (Mexican State)
Ak Chin Indian Community od Maricopa Indian Rsvn, AZ
Comanche Nation
Dominican Republic
Miami Tribe
Absentee Shawnee
Equatorial Guinea
El Salvador
England
Ethiopia
Europe Island
Estonia
Ecuador
Egypt (United Arab Republic)
Czech Republic
Falkland Islands
Fond Du Lac
Finland
French Guiana
Fiji
Florida
France
Faroe Islands
French Polynesia
French Southern and Antarctic Lands Territory of the (French)
Sac and Fox
Georgia (State)
Gabom
Greece
Georgia (Country)
Germany
Guernsey
Ghana
Guinea
Grenada
Gambia, The
Guam
Greenland
Glorioso Islands
Guadeloupe
Guerrero
South Georgia and the South Sandwich Isalnds
Guatemala
Guanajuato
Guyana
Honduras
Hawaii
Hong Kong
Hidalgo
New Hebrides (now Vanuatu)
Howland Island
Saint Helena
Haiti
Hungary
Iowa
Isle of Man
Iceland
Idaho
Ireland (does not include Northern Ireland)
India
Illinois
Madeira Islands
Indiana
Indonesia
Iraq
Iran
Israel
Italy (Includes Sicily and Sardinia)
Niue
Menominee Indian Nation
Cote d'Ivoire Republic of (Ivory Coast)
Japan
Jersey
Johnston Island
Jalisco
Jamaica
Jan Mayen
Jordan
Jarvis Island
Juan de Nova Island
Kiribati (Formerly Gilbert Islands)
Croatia
Kenya
Manihiki Island
Kingman Reef
Korea North
Korea South
Shakopee
Kansas
Kazakhstan
Kuwait
Kiowa
Kentucky
Louisiana
Liberia
Mille Lacs
Moldova
Lesotho
Slovakia
Liechtenstein
Lebanon
Slovenia
Laos
Saint Lucia
Luxembourg
Libya
Massachusetts
Manitoba
Michoacan
Maryland
Maine
Malawi
Mongolia
Marshall Islands
Michigan
Monaco
Mariana Islands
Mali
Mexico (State Unknown)
Minnesota
Missouri
Malagasy Republic (Includes Madagascar)
Morocco
Morelos
Mississippi
Montana
Mauritania
Maldives
Midway Islands
Mexico (State)
Malta
Malaysia
Nayarit
Nebraska
North Carolina
North Dakota
Holland (Netherlands)
Newfoundland (Includes Labrador)
Nigeria
New Hampshire
Northern Ireland
New Jersey
New Brunswick
Nuevo Leon
New Mexico
Nigeria
New Guinea (now Papua New Guinea)
Nepal
New Caledonia
Nauru
Nova Scotia
Northwest Territories
Nicaragua
Nevada
Norway
Netherlands Antilles
New York
New Zealand
Oaxaca
Macau (Formerly Spelled Macao)
Norfolk Island
Ohio
Okinawa
Oklahoma
Oman
Ontario
Oregon
Oglala Sioux
Pennsylania
Puebla
Pitcairn Henderson Ducie and Oeno Islands (Dependent Territory)
Republic of Palau
Prince Edward Island
Guinea Bissau (formerly Portuguese Guinea)
Philippines
Pakistan
Palmyra Atoll
Panama
Poland
Quebec
Puerto Rico
Saint Pierre and Miquelon
Portugal
Peru
Paraguay
Qatar
Quintana Roo
Queretaro
Russia
Congo Republic Of Brazzaville
China, People's Republic of
Reunion
Russia Federation
Gibraltar
Rhodesia (Now Zimbabwe)
Rhode Island
Red Lake Indian Agency
Montserrat
Spanish Sahara (now Western Sahara)
Romania/Rumania
Socialist Republic of Vietnam
Rwanda
Republic of Yemen
Sierra Leone
Saudi Arabia
South Carolina
South Dakota
Seychelles
South Africa
Senegal
San Marino
Sinaloa
Namibia (South West Africa)
San Luis Potosi
Somalia
Saskatchewan
Sonora
Spain
Sweden
Singapore
Scotland
Sudan
Svalbard
Swaziland
Russia (USSR)
Syria
Switzerland
Tamaulipas
Tabasco
Trucial States (now United Arab Emirates)
Spratly Islands
Tuamotu Archipelago
Tongoa
Thailand
Timor Portuguese
Tajikistan
Tokelau
Tlaxcala
Tromelin Island
Tennessee
Togo
Sao Tome and Principe
Tongareva Island
Turks and Caicos Islands
Saint Christopher (or St. Kitts) and Nevis
Trinidad and Tobago
Tunisia
Tuvalu (Formerly Ellice Islands)
China, Taiwan Republic of
Texas
Turkey
United Republic of Tanzania
Uganda
Ukraine
Mauritius
Turkmenistan
Utah
Burkina Faso (known as Burkina formerly Upper Volta)
Uruguay
Uzbekistan
Virginia
British Virgin Islands
Veracruz
U.S. Virgin Islands
Navassa Island
Vietnam North
Vietnam South
Vermont
Saint Vincent and the Grenadines
Vatican City
Venezuela
Washington
White Earth
Wallis and Futuna
Wisconsin
Wake Island
Wales
West Indies (for West Indies Islands not Separately listed)
Western Samoa
West Virginia
Wyoming
Yugoslavia
Mayotte, Territorial Collectivity of
Yukon (Territory)
Yucatan
All Others
Zacatecas
Martinique
Surinam
Canary Islands
Zambia
Mozambique
Congo Kinshasa Now Zaire
Country of Citizenship
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Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba (Now Independent)
Australia
Austria
Azerbaijan
Azores (Islands)
Bahamas, The
Bahrain/Bahrain
Balearic Islands
Bangladesh
Barbados
Bassas Da India
Belgium
Belize (Formerly British Honduras)
Benin (Formerly Dahomey)
Bermuda
Bhutan
Bolivia
Bosnia
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Solomon Islands (Now Solomon Islands)
British Virgin Islands
Brunei
Bulgaria
Burkina Faso (known as Burkina, formerly Upper Volta)
Burma
Burundi
Belarus
Cambodia (Formerly Khmer Republic and Kampuchea)
Cameroon
Canada (Province Unknown)
Canary Islands
Cape Verde Islands
Cayman Islands
Central African Republic
Ceylon (Now Sri Lanka)
Chad
Chile
China, People's Republic of
China, Taiwan, Republic of
Clipperton Island
Cocos (Keeling Islands)
Columbia
Comoros (or Comoros Islands)
Congo, Republic of, Brazzaville
Congo Kinshasa, Now Zaire
Cook Islands
Coral Sea Islands
Costa Rica
Côte d'Ivoire, Republic of (Ivory Coast)
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt (United Arab Republic)
El Salvador
England
Equatorial Guinea
Estonia
Ethiopia
Europa Island
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands, Territory of the (French)
Gabon
Gambia, The
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea Bissau (formerly Portuguese Guinea)
Guyana
Haiti
Holland (Netherlands)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland (does not include Northern Ireland)
Israel
Italy (Includes Sicily and Sardinia)
Jamaica
Jan Mayen
Japan
Jersey
Jordan
Juan de Nova Island
Kazakhstan
Kenya
Kiribati (formerly Gilbert Islands)
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Madeira Islands
Macau (formerly Spelled Macao)
Malagasy Republic (includes Madagascar)
Malawi
Malaysia
Maldives
Mali
Malta
Isle of Man
Manihiki Island
Martinique
Mauritania
Mauritius
Mayotte, Territorial Collectivity of
Mexico (state unknown)
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Namibia (South West Africa)
Nauru
Nepal
Netherlands Antilles
New Caledonia
New Hebrides (now Vanuatu)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Ireland
Norway
Okinawa
Oman
Pakistan
Palau, Republic of
Panama
Papua New Guinea (formerly New Guinea)
Paraguay
Peru
Philippines
Pitcairn, Henderson Ducie, and Oeno Islands (Dependent territory)
Poland
Portugal
Qatar
Republic of Yemen
Reunion
Rhodesia (now Zimbabwe)
Romania/Rumania
Russia
Russia (USSR)
Russian Federation
Rwanda
Saint Christopher (of St. Kitts) and Nevis
Saint Helena
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
Sao Tome and Principe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Socialist Republic of Vietnam
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Spanish Sahara (Now Western Sahara)
Spratly Islands
Sudan
Surinam
Svalbard
Swaziland
Sweden
Switzerland
Syria
Tajikistan
Tanzania, United Republic of
Thailand
Timor, Portuguese
Togo
Tokelau
Tonga
Tongareva Island
Trinidad and Tobago
Tromelin Island
Trucial States (now United Arab Emirates)
Tuamotu Archipelago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu (formerly Ellice Islands)
Uganda
Ukraine
Uruguay
USA (United States of America)
Uzbekistan
Vatican City
Venezuela
Vietnam, North
Vietnam, South
Wales
Wallis and Futuna
West Indies (for West Indies Islands not separately Listed)
Western Samoa
British Columbia
Manitoba
New Brunswick
Newfoundland (includes Labrador)
Northwest Territories
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon (Territory)
Aguascalientes
Baja California (Northern Section)
Baja California (Southern Section)
Campeche
Chiapas
Chihuahua
Coahuila
Colima
Distrito Federal (Mexico, D.F.)
Durango
Guanajuato
Guerrero
Hidalgo
Jalisco
Mexico (State)
Michoacan
Morelos
Nayarit
Nuevo Leon
Oaxaca
Puebla
Queretaro
Quintana Roo
San Luis Potosi
Sinaloa
Sonora
Tabasco
Tamaulipas
Tlaxcala
Veracruz
Yucatan
Zacatecas
Emergency Contact
*
Emergency Contact phone number
*
Phone
form field Emergency Contact phone number
must be in the format: (000) 000-0000
Emergency Contact address
*
Emergency Contact Relationship to you
*
Value is not selected
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Aunt
Brother
Cousin
Daughter
Father
Former Husband
Father-In-Law
Friend
Former Wife
Grandparent
Husband
Mother-In-Law
Mother
Sister
Son
Wife
Uncle
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