Transcription of REQUEST FOR LIVE SCAN SERVICE - CASOMB
1 STATE OF CALIFORNIADEPARTMENT OF JUSTICEBCII 8016 (orig. 4/01; rev. 6/09) REQUEST FOR live scan SERVICE 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:OCA Number (Agency Identifying Number)Level of SERVICE : DOJ FBIIf re-submission, list original ATI number: (Must provide proof of rejection)Original ATI Number Employer (Additional response for agencies specified by statute):Employer NameStreet Address or BoxCityStateZIP CodeMail Code (five digit code assigned by DOJT elephone Number (optional) live scan Transaction Completed By:Name of OperatorDateTransmitting AgencyLSIDATI NumberAmount Collected/Billed ORIGINAL - live scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting AgencyAF227 SOMB PROFESS CERT 9003 PCSOMB PROFESS CERT 9003 PCCASBSEX OFFENDER MGT BD163291515 S ST.)
3 RM. 212 NORTHSACRAMENTOCA95811152027
