Bcia 8016visa, Request For Live Scan Service
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1
2STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
BCIA 8016VISA
PAGE 1 of 2
(Orig. 04/2001; Rev. 02/2017)
REQUEST FOR LIVE SCAN SERVICE
Print Form
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(
)
VISA/Immigration
Applicant Submission
AE709
VISA/IMMIGRATION
Authorized Applicant Type
ORI (
)
Code assigned by DOJ
Type of License/Certification/Permit OR Working Title (
)
Maximum 30 characters - if assigned by DOJ, use exact title assigned
Contributing Agency Information:
DEPARTMENT OF JUSTICE
N/A
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
P.O. Box 903387
Applicant Program
Street Address or P.O. Box
Contact Name (mandatory for all school submissions)
SACRAMENTO
CA
94203-3870
916-210-4239
State
City
ZIP Code
Contact Telephone Number
Applicant Information:
Last Name
First Name
Middle Initial
Suffix
Other Name
Suffix
(AKA or Alias) Last
First
Male
Female
Sex
Date of Birth
Driver's License Number
Billing
N/A
Number
Height
Weight
Eye Color
Hair Color
(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
N/A
DOJ
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):
N/A
N/A
Employer Name
Mail Code (five digit code assigned by DOJ)
N/A
Street Address or P.O. Box
N/A
N/A
N/A
N/A
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
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