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Live Scan Fingerprinting
DNA Testing
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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:A0071
License/Certification/Permit
Authorized Applicant Type
RPH Renewal - Section 1702
Type of License/Certification/Permit OR Working Title ( Maximum 30 characters - if assigned by DOJ, use exact title assigned )
Agency Address Set Contributing Agency
Agency Authorized to Receive Criminal Record Information
05712
Mail Code(five-digit code assigned by DOJ)
2720 Gateway Oaks Drive, Suite 100
Street Address or P.O. Box
Licensing
Contact Name (mandatory for all school submissions)
Sacramento,
City
CA
State
95833
Zip Code
9165183100
City State ZIP Code
Applicant Information: Live Scan Operator – The Board of Pharmacy requires you to enter the applicant’s SSN.
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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