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Live Scan Fingerprinting
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Home
Forms
About
Services
Live Scan Fingerprinting
DNA Testing
Drug Testing
Schedule Appointment
Contact Us
Home
Forms
About
Services
Live Scan Fingerprinting
DNA Testing
Drug Testing
Schedule Appointment
Contact Us
Home
Forms
About
Services
Live Scan Fingerprinting
DNA Testing
Drug Testing
Schedule Appointment
Contact Us
Adult Care | Child Care | Children's Residential | Home Care | Senior Care | Foster Family
ORI: A0448
Working Title: (Check one)
Adult Resident other than Client
Employee
License, Certification, Applicant
Volunteer
Home Care Aide Registry Applicant
Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type.
CA Dept of Social Services
Agency authorized to receive criminal history information
03502
Mail Code(five-digit code assigned by DOJ)
PO BOX 94244
Street No.
Mail Station 9-15-62
Street or PO Box
N/A
Contact Name(Mandatory for all school submissions)
Sacramento,
City
CA
State
CA
State
Contact Telephone No.
Applicant Information:
Name of Applicant: (Please print)
First Name
Last Name
MI
AKA’s:
Last Name
First Name
CDL No.
DOB:
Sex
Male
Female
Misc. No.
BIL
HT:
WT:
Eye Color
Hair Color
Misc. No.:
Home Address: (All applicants must complete)
POB:
STREET OR PO BOX
SOC
CITY, STATE AND ZIP CODE
Facility/Organization Number:
Level of Service
DOJ
FBI
If resubmission for fingerprint quality (select R2), list Original ATI No
Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
Employer Name
Street No.
Street or PO Box
Mail Code (five digit code assigned by DOJ)
City
State
Zip Code
Agency Telephone No. (Optional)
Live Scan Transaction Completed By:
Name of Operator
Date
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
SUBMIT
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