Form Sos/bcii 8016 - Request For Live Scan Service
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1
2REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
ORI:
A0084
License, Certification or Permit
Type of Application:
________________
Code assigned by DOJ
Notary Public
Job Title or Type of License, Certification or Permit:
________________________________
Agency Address Set Contributing Agency
Secretary of State
03690
__________________________
Agency authorized to receive criminal history information
Mail Code (five digit assigned by DOJ)
th
nd
1500 11
Street, 2
Floor
_____________________________________
Street No.
Street or P.O. Box
Contact Name (Mandatory for all school submissions)
Sacramento
CA
95814___
(
)
__________________________________________
City
State
Zip Code
Contact Telephone No.
_____________________________________________________________________
Name of Applicant:
(please print)
Last
First
MI
_________________________________
___________________________
Alias:
Driver’s License No.
L
ast
First
____________
______________________________
Date of Birth:
SEX:
Male
Female Misc. No. BIL -
APPLICANT MUST PAY AT LIVE SCAN SITE
Agency Billing Number
____________
_____________
_________________________________
Height:
Weight:
Misc. No:
__________
___________
_____________________________
Eye Color:
Hair Color:
Home Address:
Street or P.O. Box
___________________________
_____________________________
Place of Birth:
City, State and Zip Code
____________________
Social Security Number:
___________________________
Your Number:
Level of Service
DOJ
FBI
X
X
OCA No.
_____________
If resubmission, list Original ATI No.
Employer: (Additional response for agencies specified by statute)
_____________________________________
Employer Name
_____________________________________
________________________________________
DOJ)
Street No.
Street or P.O. Box
Mail Code (five digit code assigned by
_____________________________________
________________________________________
(
)
City
State
Zip Code
Agency Telephone No. (optional)
_______________________________
_____________________
Live Scan Transaction Completed By:
Date:
Name of Operator
________________________________
_______________________
_______________________
Transmitting Agency
ATI No.
Amount Collected/Billed
SOS/BCII 8016 (Rev 04/01)
ORIGINAL-Live Scan Operator;
SECOND COPY-Requesting Agency;
THIRD COPY-Applicant
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Parent category: Life