Read BCIA 8016 - Request for Live Scan Service text version

STATE OF CALIFORNIA BCIA 8016 (orig. 04/2001; rev. 01/2011)

DEPARTMENT OF JUSTICE

REQUEST FOR LIVE SCAN SERVICE

Applicant Submission

ORI (Code assigned by DOJ) Authorized Applicant Type

Print Form

Reset Form

Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)

Contributing Agency Information:

Agency Authorized to Receive Criminal Record Information Street Address or P.O. Box City State ZIP Code Mail Code (five-digit code assigned by DOJ)

Contact Name (mandatory for all school submissions)

Contact Telephone Number

Applicant Information:

Last Name Other Name (AKA or Alias) Last Date of Birth Height Weight Sex Male Female First Name First Driver's License Number Billing Number Misc. Number Middle Initial Suffix Suffix

Eye Color

Hair Color

(Agency Billing Number)

Place of Birth (State or Country) Home Address

Social Security Number

(Other Identification Number)

Street Address or P.O. Box

City

State

ZIP Code

Your Number:

OCA Number (Agency Identifying 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 Street Address or P.O. Box

City State ZIP Code

Original ATI Number

Mail Code (five digit code assigned by DOJ)

Telephone Number (optional)

Live Scan Transaction Completed By:

Name of Operator Transmitting Agency LSID Date ATI Number

SECOND COPY - Applicant

Amount Collected/Billed

THIRD COPY (if needed) - Requesting Agency

ORIGINAL - Live Scan Operator

Information

BCIA 8016 - Request for Live Scan Service

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