Request For Live Scan Service Form – BCIA 8016

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE GENERIC LIVE SCAN FORM

Call for fees

ORI (Code assigned by DOJ )

Authorized Applicant Type

Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned )

Contributing Agency Information

Agency Authorized to Receive Criminal Record Information

Mail Code (five-digit code assigned by DOJ)

Street Address or P.O. Box

Contact Name (mandatory for all school submissions)

City

State

ZIP Code

Contact Telephone Number

Applicant Information:

Last Name

First Name

Suffix

Other Name (AKA or Alias)

Last

First

Suffix

Date of Birth

Sex

Male Femai

Driver's License Number

Height

Weight

Eye Color

Hair Color

Billing Number

Place of Birth (State or Country)

Social Security Number

Misc. Number

Home Address

Street Address or P.O. Box

City

State

ZIP Code

Your Number:

OCA Number (Agency Identifying Number)

Level of Service:

DOJ FBI

If re-submission, list original ATI number: (Must provide proof of rejection)

Original ATI Number

Employer (Additional response for agencies specified by statute):

Employer Name

Mail Code (five digit code assigned by DOJ)

Street Address or P.O. Box

City

State

ZIP Code

Telephone Number (optional)

Live Scan Transaction Completed By:

Name of Operator

Date

Transmitting Agency

LSID

ATI Number

Amount Collected/Billed

ORIGINAL - Live Scan Operator

SECOND COPY - Applicant

THIRD COPY (if needed) - Requesting Agency

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STATE OF CALIFORNIA DEPARTMENT OF JUSTICE GENERIC LIVE SCAN FORM

Call for fees

Contributing Agency Information

Applicant Information:

Other Name (AKA or Alias)

Home Address

Your Number:

If re-submission, list original ATI number: (Must provide proof of rejection)

Employer (Additional response for agencies specified by statute):

Live Scan Transaction Completed By:

ORIGINAL - Live Scan Operator

SECOND COPY - Applicant

THIRD COPY (if needed) - Requesting Agency

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