Registered Dental Hygienists Live Scan Form (RDH)

DENTAL HYGIENE COMMITTEE OF CALIFORNIA REGISTERED DENTAL HYGIENIST (RDH) LICENSE LIVE SCAN REQUEST FORM

Call for fees

REQUEST FOR LIVE SCAN SERVICE

A0638

ORI (Code assigned by DOJ)

Type of Application:

License, Certification, Permit

Job Title or Type of License, Certification or Permit:

Agency Address Set Contributing Agency:

Dental Hygiene Committee of California

Agency authorized to receive criminal history

05635

Mail Code (five-digit assigned by DOJ)

2005 Evergreen Street, Suite 2050

Street No. Street or PO Box

Contact Name (Mandatory for all school submissions)

Sacramento

City

CA

State

95815

Zip Code

(916) 263-1978

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 HYGIENE COMMITTEE OF CALIFORNIA REGISTERED DENTAL HYGIENIST (RDH) LICENSE LIVE SCAN REQUEST FORM

Call for fees

REQUEST FOR LIVE SCAN SERVICE

A0638

ORI (Code assigned by DOJ)

Agency Address Set Contributing Agency:

Dental Hygiene Committee of California

Agency authorized to receive criminal history

05635

Mail Code (five-digit assigned by DOJ)

2005 Evergreen Street, Suite 2050

Street No. Street or PO Box

Sacramento

City

CA

State

95815

Zip Code

(916) 263-1978

Contact Telephone No

Name of Applicant: (Please Print)

AKA’s

Live Scan Transaction Completed By:

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Contact Info