Transcription of California Live Scan Request Form for Registered Nurse (RN ...
1 DEPARTMENT OF JUSTICESTATE OF CALIFORNIABCIA 8016 (orig. 04/2001; rev. 01/2011)Fingerprint Application Form BCIA 8016 Applicant SubmissionORI (Code assigned by DOJ)Authorized Applicant TypeType 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 InformationMail Code (five-digit code assigned by DOJ)Street Address or BoxCityStateZIP CodeContact Name (mandatory for all school submissions)Contact Telephone NumberApplicant Information:Last NameFirst Name Middle InitialSuffixOther Name (AKA or Alias)LastFirstSuffixDate of BirthSexMaleFemaleDriver's License NumberHeightWeightEye ColorHair ColorPlace of Birth (State or Country)Social Security NumberHome AddressStreet Address or BoxCityStateZIP CodeBilling Number(Agency Billing Number)Misc.
2 Number(Other Identification Number)Your Number: RN #OCA Number (Agency Identifying Number)Level of Service: DOJ FBIIf re-submission, list original ATI number: (Must provide proof of rejection)Original ATI NumberEmployer (Additional response for agencies specified by statute):Employer NameStreet Address or BoxCityStateZIP CodeMail Code (five digit code assigned by DOJ)Telephone Number (optional)Live Scan Transaction Completed By:Name of OperatorDateTransmitting AgencyLSIDATI NumberAmount Collected/BilledORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting AgencyCALIFORNIA Registered Nurse (RN) LICENSE LIVE SCAN Request FORMA pplicant must contact their Contributing Agency to verify the accuracy of the form required for their Live Scan submission.
