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REQUEST FOR LIVE SCAN SERVICE - rn.ca.gov

STATE OF CALIFORNIADEPARTMENT OF JUSTICEBCIA 8016 (orig. 04/2001; rev. 01/2011) 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.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BCIA 8016 (orig. 04/2001; rev. 01/2011) REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI (Code assigned by DOJ) Authorized Applicant Type

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Transcription of REQUEST FOR LIVE SCAN SERVICE - rn.ca.gov

1 STATE OF CALIFORNIADEPARTMENT OF JUSTICEBCIA 8016 (orig. 04/2001; rev. 01/2011) 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: RN #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 DOJ)Telephone 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 AgencySTATE OF CALIFORNIADEPARTMENT OF JUSTICEBCIA 8016 (orig. 04/2001; rev. 01/2011) 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.

3 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. 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 Number Employer (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/Billed ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting AgencySTATE OF CALIFORNIADEPARTMENT OF JUSTICEBCIA 8016 (orig.)

4 04/2001; rev. 01/2011) 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.

5 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 Number Employer (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/Billed ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency


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