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Request For Live Scan Service: Print Clear Form

This document is a request form for a live scan service background check from the California Department of Justice. It contains fields for information about the applicant such as name, date of birth, address, and fingerprints. The form also includes fields for information about the agency requesting the background check and the reason for the application.

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davhorner
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© Attribution Non-Commercial (BY-NC)
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134 views1 page

Request For Live Scan Service: Print Clear Form

This document is a request form for a live scan service background check from the California Department of Justice. It contains fields for information about the applicant such as name, date of birth, address, and fingerprints. The form also includes fields for information about the agency requesting the background check and the reason for the application.

Uploaded by

davhorner
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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State of California Department of Justice

Print Clear Form


REQUEST FOR LIVE SCAN SERVICE
BCII 8016 RR (11/09)

Applicant Submission

ORI: CA0349435 Type of Application: Record Review Foreign Adoption


Code assigned by DOJ (Check One Only)

(Job Title) Reason for Application:

Agency Address Set Contributing Agency:

California Department of Justice 07041


Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ
P.O. Box 903417 Record Review Unit
Street No. Street or PO Box Contact Name

Sacramento CA 94203-4170 ( 916 ) 227-3849


City State Zip Code Contact Telephone No.

Name of Applicant:
(Please print) Last First MI

Alias: Driver’s License No:


Last First

Date of Birth: Sex: Male Female Misc. No. BIL -


Agency Billing Number

Height: Weight:
Applicant's Address:

Eye Color: Hair Color: Street No. Street or PO Box

Place of Birth: City, State and Zip Code

Social Security Number: Daytime Telephone Number

If resubmission, list Original ATI Level of Service: X DOJ Only


Number:

Foreign Government Embassy: (MANDATORY FOR FOREIGN ADOPTION REQUESTS ONLY)

Embassy Name

Street No. Street or PO Box

( )
City Country Zip Code Embassy Telephone No. (optional)

Live Scan Transaction Completed By:


Name of Operator Date

Transmitting Agency ATI No. Amount Collected/Billed

ORIGINAL – Live Scan Operator; SECOND COPY – Applicant; THIRD COPY (if needed) – Requesting Agency

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