Licensed Dentist Live Scan Form (DDS)

DENTAL BOARD OF CALIFORNIA DENTIST (DDS) LICENSE LIVE SCAN REQUEST FORM

REQUEST FOR LIVE SCAN SERVICE

A0023

ORI (Code assigned by DOJ)

Type of Application: (check one)

Employment License, Certification, Permit Volunteer

Agency Address Set Contributing Agency:

DENTAL BOARD OF CALIFORNIA

Agency authorized to receive criminal history

06129

Mail Code (five-digit assigned by DOJ)

2005 Evergreen Street, Suite 1550

Street No. Street or PO Box

EXAMINATION UNIT

Contact Name (Mandatory for all school submissions)

Sacramento

City

CA

State

1550

Zip Code

(916) 263-2300

Contact Telephone No.

Name of Applicant: (Please Print)

Last

First

AKA’s

Last

First

CDL No

DOB:

HT:

HAIR color:

Misc. No.:

POB:

Street or PO Box

SOC:

City, State and Zip Code

Your Number:

Level Of Service

DOJ FBI

If resubmission, 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

ATI No.

Amount Collected/Billed

BCII 8016 (Rev10/98) ORIGINAL-Live Scan Operator, SECOND COPY-Requesting Agency; THIRD COPY-Applicant

DENTAL BOARD OF CALIFORNIA DENTIST (DDS) LICENSE LIVE SCAN REQUEST FORM

REQUEST FOR LIVE SCAN SERVICE

A0023

ORI (Code assigned by DOJ)

Agency Address Set Contributing Agency:

DENTAL BOARD OF CALIFORNIA

Agency authorized to receive criminal history

06129

Mail Code (five-digit assigned by DOJ)

2005 Evergreen Street, Suite 1550

Street No. Street or PO Box

EXAMINATION UNIT

Contact Name (Mandatory for all school submissions)

Sacramento

City

CA

State

1550

Zip Code

(916) 263-2300

Contact Telephone No.

Name of Applicant: (Please Print)

AKA’s

Live Scan Transaction Completed By:

Quick Links

Contact Info