REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
ORI: ___________________
Type of Application:
____________________________________________________________________________________
Code assigned by DOJ
Job Title or Type of License, Certification or Permit:
Agency Address Set Contributing Agency:
Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
Street No.
Street or PO Box
Contact Name (Mandatory for all school submissions)
(
)
City
State
Zip Code
Contact Telephone No.
Name of Applicant:
(Please print)
Last
First
MI
Driver's License No. _________________________________
Alias:
Last
First
Date of Birth: ____________ SEX:
Male
Female
Misc. No. BIL - ________________________________
Agency Billing Number (if applicable)
Weght: _________________
Misc. No.
Height: __________________
Eye Color:
Hair Color:
Home Address:
Street or P.O. Box
Place of Birth: _________________________________
City, State and Zip Code
SOC:
Level of Service
DOJ
FBI
Your Number:
OCA No. (Agency Identifying No.)
If resubmission, list Original ATI No. _______________________
Employer:
(Additional response for agencies specified by statute)
Employer Name
Street or PO Box
Mail Code (five digit code assigned by DOJ)
Street No.
(
)
State
Zip Code
Agency Telephone No. (Optional)
City
Live Scan Transaction Completed By:
Date: ___________________________
Name of Operator
ATI No.
Amount Collected/Billed
Transmitting Agency
ORIGINAL-Live Scan Operator; SECOND COPY-Requesting Agency; THIRD COPY-Applicant
BCII 8016 (Rev04/01)