Live Scan Form - Structural Pest Control Board
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1STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
Print Form
Reset Form
Applicant Submission
LICENSE, CERTIFICATION, PERMIT
A1099
Authorized Applicant Type
ORI (
)
Code assigned by DOJ
STRUCTURAL PEST CONTROL
Type of License/Certification/Permit OR Working Title (
)
Maximum 30 characters - if assigned by DOJ, use exact title assigned
Contributing Agency Information:
DCA / STRUCTURAL PEST CONTROL BOARD
A06058
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
2005 EVERGREEN STREET, SUITE 1500
JAMIE ENSCOE / RONNI O'FLAHERTY
Street Address or P.O. Box
Contact Name (mandatory for all school submissions)
CA
95815
(916) 561-8704
SACRAMENTO
City
State ZIP Code
Contact Telephone Number
Applicant Information:
Last Name
First Name
Middle Initial
Suffix
Other Name
(AKA or Alias) Last
First
Suffix
Male
Female
Sex
Date of Birth
Driver's License Number
Billing
Height
Weight
Eye Color
Hair Color
Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country)
Social Security Number
Number
(Other Identification Number)
Home
Address Street Address or P.O. Box
City
State
ZIP Code
DOJ
FBI
Level of Service:
Your Number:
OCA Number (Agency Identifying Number)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Employer Name
Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City
State
ZIP Code
Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator
Date
Transmitting Agency
LSID
ATI Number
Amount Collected/Billed
ORIGINAL - Live Scan Operator
SECOND COPY - Applicant
THIRD COPY (if needed) - Requesting Agency
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