Professional Fiduciaries Bureau

REQUEST FOR LIVE SCAN SERVICE

Entertainment Firearms Permit Application Request for Live Scan Service

Call For Fee

AA490

ORI (Code assigned by DOJ)

Entertainment Firearms Permit Application

Authorized Applicant Type

Prof Fid License 6533 BPC

Professional Fiduciary

Agency Address Set Contributing Agency:

Agency authorized to receive criminal history information

11845

Mail Code (five-digit code assigned by DOJ)

1625 N. Market Blvd., Ste. S-209

Street Address or P.O. Box

N/A

Contact Name (mandatory for all school submissions)

Sacramento

City

CA

State

95834

Zip Code

(916) 574-7340

Contact Telephone No .

Applicant Information:

Last Name

First Name

Middle Initia

Suffix

Alias:

Last Name

First Name

Suffix

DOB:

Sex

Male Female

Driver's License N o.

HT:

WT:

Hair Color

Eye Color

BIL

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:

Level of Service:

DOJ FBI

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

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

Applicant must contact their Contributing Agency to verify the accuracy of the form required for their Live Scan submission.

REQUEST FOR LIVE SCAN SERVICE

Entertainment Firearms Permit Application Request for Live Scan Service

Call For Fee

AA490

ORI (Code assigned by DOJ)

Entertainment Firearms Permit Application

Authorized Applicant Type

Prof Fid License 6533 BPC

Professional Fiduciary

Agency Address Set Contributing Agency:

Professional Fiduciaries Bureau

Agency authorized to receive criminal history information

11845

Mail Code (five-digit code assigned by DOJ)

1625 N. Market Blvd., Ste. S-209

Street Address or P.O. Box

N/A

Contact Name (mandatory for all school submissions)

Sacramento

City

CA

State

95834

Zip Code

(916) 574-7340

Contact Telephone No .

Applicant Information:

Alias:

Home Address

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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Contact Info