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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
REQUEST FOR LIVE SCAN SERVICE
Call For Fees
ORI:A0435
License, Certification, Permit
Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned )
Psychologist
Psych Testing Tech
Research Psychoanalyst
Psychological Associate
Student Research Psychoanalyst
Contributing Agency Information:
BOARD OF PSYCHOLOGY
Agency Authorized to Receive Criminal Record Information
05637
Mail Code(five-digit code assigned by DOJ)
1625 North Market Blvd., Suite N-215
Street Address or P.O. Box
N/A
Contact Name (mandatory for all school submissions)
Sacramento,
City
CA
State
95834
Zip Code
N/A
City State ZIP Code
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
ATI No.
Amount Collected/Billed
SUBMIT
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