Fillable AND PRIVACY NOTICES INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING (California)

Fill Online, Printable, Fillable, Blank AND PRIVACY NOTICES INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING (California) Form

Use Fill to complete blank online CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

AND PRIVACY NOTICES INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING (California)

On average this form takes 21 minutes to complete

The AND PRIVACY NOTICES INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING (California) form is 9 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 78 other fields

Country of origin: US
File type: PDF

BROWSE CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
37A-648 (Revised 06/2020) 1
STATE OF CALIFORNIA - BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY Gavin Newsom, Governor
Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830
www.bbs.ca.gov
INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING
AND PRIVACY NOTICES
Live Scan Fingerprinting is available only in California. Live Scan fingerprint results will be
submitted to the Department of Justice (DOJ) and the Federal Bureau of Investigation
(FBI) electronically.
If you need to have your fingerprints taken in another state, you must use the "hard card"
fingerprint method. To request hard cards and instructions, send an email to
BBS.Fingerprint@dca.ca.gov with "Fingerprint Hard Cards" in the subject line, and include
your mailing address. Please be advised that the DOJ processing time for hard card
fingerprints is a minimum of 8 to 12 weeks, or longer. In order to avoid processing delays
and additional costs that result from invalid fingerprint cards, fingerprints must be taken at a
law enforcement agency in the state of residence.
Fingerprint Fees - Paid to Live Scan Site
If you have your prints taken via Live Scan, you must pay the fingerprint fees below
directly to the site where you have your Live Scan fingerprints taken:
DOJ FINGERPRINT PROCESSING FEE: $32.00
FBI FINGERPRINT PROCESSING FEE: $17.00
In addition to these processing fees, there may be a service charge associated with
the Live Scan site you visit. The Live Scan service site will collect the above fees at the
time you are fingerprinted. The Live Scan service charge may vary from location to
location.
Complete the Request for Live Scan Service Form
You must complete and submit the attached Request for Live Scan Service form at the
Live Scan site. Make sure that the information provided in Section 3 of the form matches
the information on your BBS application. Once your fingerprints have been scanned, the
Live Scan Operator will complete Section 4 of this form and return the second and third
copies to you.
The second copy of this form, with Section 4 completed by the Live Scan Operator,
must be MAILED to the BBS in order to retrieve your fingerprint results from the DOJ.
Retain the third copy for your records as a proof of payment.
37A-648 (Revised 06/2020) 2
Live Scan Fingerprint Locations
You must visit an approved Live Scan Service Site. Most local Police and Sheriff
Departments offer the Live Scan fingerprinting service. Some large school districts,
passport services, and stores with generalized fingerprinting expertise may also offer Live
Scan. A current listing of Live Scan sites is available on the DOJ website at
https://oag.ca.gov/fingerprints/locations.
Consider calling the Live Scan service provider for hours of operation, fees, and
appointment times if necessary. You must present valid photo identification (i.e., driver’s
license, military ID, or passport) at the Live Scan site.
Filling Out Your Live Scan Form
To facilitate prompt and accurate processing, please TYPE or print legibly in ink.
SECTION 1: Type of Application: LIC/CERT/PERMIT
Check the box for the applicable registration or license you are applying for with the BBS.
Even if you are applying for more than one registration or license type, CHECK THE BOX
FOR ONLY ONE LICENSE TYPE. Your fingerprint results will be put towards ALL
registrations and licenses you hold. You do not need to pay or be fingerprinted for each
individual BBS license type.
SECTION 2: This section is already completed.
SECTION 3:
Name of Applicant: Enter your full name
Alias: Indicate all other names used
Date of Birth: Indicate your month/day/year of birth
Sex: Mark the appropriate box
Height: Indicate your height in feet and inches
Weight: Indicate your weight in pounds (lbs.)
Eye Color: Indicate eye color abbreviation:
BLK - Black
GRY - Gray
MAR - Maroon
BLU - Blue
GRN - Green
PNK – Pink
BRO - Brown
HAZ - Hazel
MUL - Multicolor
Hair Color: Indicate hair color abbreviation:
BAL - Bald
BRO - Brown
SDY - Sandy
BLK - Black
GRY - Gray
WHI - White
BLN - Blonde
RED - Red
37A-648 (Revised 06/2020) 3
Place of Birth:
Social Security
Number:
Driver’s License
No:
Indicate the state or country of birth
Enter your SSN or individual taxpayer ID number. Must match the
number provided on your application.
Enter your Driver’s license number if you have one.
Address: Enter a mailing address of your choice. You may use a business
address, your home address, or any current address. This
address will not be viewable by the public, and will be used
solely for the BBS’ records.
Your BBS File number:
Enter your BBS file number. If you are a brand new applicant and do not currently hold an
identifying number, leave this line blank.
If Resubmission, list Original ATI No.
This is only used for a second fingerprinting due to a prior fingerprint rejection. The ATI No.
allows you to be re-fingerprinted without paying the DOJ and FBI processing fee (service
charges may still apply.)
Applicant Signature
Sign and date the application to indicate that you have read the included Privacy Notice,
Privacy Act Statement and Applicant’s Privacy Rights.
SECTION 4:
To be completed by the Live Scan operator.
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services
(CJIS) Division in the Department of Justice (DOJ) collects the information requested on this
form as authorized by Business and Professions Code sections 4600-4621, 7574-7574.16,
26050-26059, 11340-11346, and 22440-22449; Penal Code sections 11100-11112, and
11077.1; Health and Safety Code sections 1522, 1416.20-1416.50, 1569.10-1569.24, 1596.80-
1596.879, 1725-1742, and 18050-18055; Family Code sections 8700-87200, 8800-8823, and
8900-8925; Financial Code sections 1300-1301, 22100-22112, 17200-17215, and 28122-
28124; Education Code sections 44330-44355; Welfare and Institutions Code sections 9710-
9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes and
regulations. The CJIS Division uses this information to process requests of authorized entities
that want to obtain information as to the existence and content of a record of state or federal
convictions to help determine suitability for employment, or volunteer work with children, elderly,
or disabled; or for adoption or purposes of a license, certification, or permit. In addition, any
personal information collected by state agencies is subject to the limitations in the Information
Practices Act and state policy. The DOJ's general privacy policy is available at
http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be
provided. Failure to provide all the necessary information will result in delays and/or the
rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in
the DOJ that contain your personal information, as permitted by the Information Practices Act.
See below for contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to
Live Scan service to help determine the suitability of a person applying for a license,
employment, or a volunteer position working with children, the elderly, or the disabled, we may
need to share the information you give us with authorized applicant agencies. The information
you provide may also be disclosed in the following circumstances:
• With other persons or agencies where necessary to perform their legal duties, and their
use of your information is compatible and complies with state law, such as for
investigations or for licensing, certification, or regulatory purposes.
• To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may
contact the Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916)
210-3310, by email at keeperofrecords@doj.ca.gov, or by mail at: Department of Justice Bureau
of Criminal Information & Analysis Keeper of Records P.O. Box 903417 Sacramento, CA
94203-4170.
REQUEST FOR LIVE SCAN SERVICE
Privacy Act Statement
Authority. The FBI's acquisition, preservation, and exchange of fingerprints and associated
information is generally authorized under 28 U.S.C. 534. Depending on the nature of your
application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L.
92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and
associated information is voluntary; however, failure to do so may affect completion or approval
of your application.
Principal Purpose. Certain determinations, such as employment, licensing, and security
clearances, may be predicated on fingerprint-based background checks. Your fingerprints and
associated information/biometrics may be provided to the employing, investigating, or otherwise
responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other
fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems
(including civil, criminal, and latent fingerprint repositories) or other available records of the
employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints
and associated information/biometrics in NGI after the completion of this application and, while
retained, your fingerprints may continue to be compared against other fingerprints submitted to
or retained by NGI.
Routine Uses. During the processing of this application and for as long thereafter as your
fingerprints and associated information/biometrics are retained in NGI, your information may be
disclosed pursuant to your consent, and may be disclosed without your consent as permitted by
the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the
Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine
Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental, or
authorized non-governmental agencies responsible for employment, contracting, licensing,
security clearances, and other suitability determinations; local, state, tribal, or federal law
enforcement agencies; criminal justice agencies; and agencies responsible for national security
or public safety.
REQUEST FOR LIVE SCAN SERVICE
Noncriminal Justice Applicant's Privacy Rights
As an applicant who is the subject of a national fingerprint-based criminal history record check for a
noncriminal justice purpose (such as an application for employment or a license, an immigration or
naturalization matter, security clearance, or adoption), you have certain rights which are discussed
below.
• You must be provided written notification
1
that your fingerprints will be used to check the
criminal history records of the FBI.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement
when you submit your fingerprints and associated personal information. This Privacy Act
Statement should explain the authority for collecting your information and how your
information will be used, retained, and shared.
2
• If you have a criminal history record, the officials making a determination of your suitability for
the employment, license, or other benefit must provide you the opportunity to complete or
challenge the accuracy of the information in the record
.
• The officials must advise you that the procedures for obtaining a change, correction, or
update of your criminal history record are set forth at Title 28, Code of Federal Regulations
(CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time to
correct or complete the record (or decline to do so) before the officials deny you the
employment, license, or other benefit based on information in the criminal history record
.
3
You have the right to expect that officials receiving the results of the criminal history record check
will use it only for authorized purposes and will not retain or disseminate it in violation of federal
statute, regulation or executive order, or rule, procedure or standard established by the National
Crime Prevention and Privacy Compact Council.
4
If agency policy permits, the officials may provide you with a copy of your FBI criminal history record
for review and possible challenge. If agency policy does not permit it to provide you a copy of the
record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.
Information regarding this process may be obtained at
https://www.fbi.gov/services/cjis/identity-
history-summary-checks
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you
should send your challenge to the agency that contributed the questioned information to the FBI.
Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your
challenge to the agency that contributed the questioned information and request the agency to verify
or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI
will make any necessary changes/corrections to your record in accordance with the information
supplied by that agency. (See 28 CFR 16.30 through 16.34.) You can find additional information on
the FBI website at https://www.fbi.gov/about-us/cjis/background-checks
1 Written notification includes electronic notification, but excludes oral notification
2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3 See 28 CFR 50.12(b) 4 See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. §
14616), Article IV(c)
4 See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)
State of California
REQUEST FOR LIVE SCAN SERVICE
BCII 8016 (04/2020)
Applicant Submission
APPLICANT
SECTION 1
ORI: A0462
(Code assigned by DOJ)
Type of License: (Mark Only ONE)
Marriage and Family Therapist
Educational Psychologist
Type of Application: LIC/CERT/PERMIT
Clinical Social Worker
Professional Clinical Counselor
SECTION 2
Agency Authorized to Receive Criminal Record
Information:
Board of Behavioral Sciences
1625 North Market Blvd. Suite S-200
Sacramento CA 95834
Mail Code: 01484
Contact Name: Fingerprint Unit
Contact Phone: (916) 574-7859
SECTION 3
Name of Applicant: ______________________________
(Please Print) Last
Alias: _________________________________________
Last First
Date of Birth: ____________ Sex: Male Female
Height: ________________ Weight: _______________
Eye Color: _____________ Hair Color: ____________
Place of Birth: __________________________________
Social Security Number: __________________________
_____________________________ ______
First MI
Driver’s License No.: ____________________
Billing No.: APPLICANT MUST PAY
Address:
______________________________________
Number and Street
________________________ ____ ________
City State Zip
BBS File Number: __________________________
If Resubmission, list Original ATI No.:
_________________________________________
(Must provide proof of rejection)
BBS Applicant: Please mail a copy of this
form to the address in Section 2 with your
BBS application.
Level of Service: DOJ FBI
I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.
Applicant Signature: _____________________________________ Date: __________
SECTION 4
Live Scan Transaction Completed By: ____________________________________ Date: _____________
Transmitting Agency: ___________________________________________ LSID: __________________
ATI No.: _________________________ Amount Collected/Billed: _______________________________
ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant
37A-649 (Revised 06/2020)
State of California
REQUEST FOR LIVE SCAN SERVICE
BCII 8016 (04/2020)
Applicant Submission
APPLICANT
SECTION 1
ORI: A0462
(Code assigned by DOJ)
Type of License: (Mark Only ONE)
Marriage and Family Therapist
Educational Psychologist
Type of Application: LIC/CERT/PERMIT
Clinical Social Worker
Professional Clinical Counselor
SECTION 2
Agency Authorized to Receive Criminal Record
Information:
Board of Behavioral Sciences
1625 North Market Blvd. Suite S-200
Sacramento CA 95834
Mail Code: 01484
Contact Name: Fingerprint Unit
Contact Phone: (916) 574-7859
SECTION 3
Name of Applicant: ______________________________
(Please Print) Last
Alias: _________________________________________
Last First
Date of Birth: ____________ Sex: Male Female
Height: ________________ Weight: _______________
Eye Color: _____________ Hair Color: ____________
Place of Birth: __________________________________
Social Security Number: __________________________
_____________________________ ______
First MI
Driver’s License No.: ____________________
Billing No.: APPLICANT MUST PAY
Address:
______________________________________
Number and Street
________________________ ____ ________
City State Zip
BBS File Number: __________________________
If Resubmission, list Original ATI No.:
_________________________________________
(Must provide proof of rejection)
BBS Applicant: Please mail a copy of this
form to the address in Section 2 with your
BBS application.
Level of Service: DOJ FBI
I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.
Applicant Signature: _____________________________________ Date: __________
SECTION 4
Live Scan Transaction Completed By: ____________________________________ Date: _____________
Transmitting Agency: ___________________________________________ LSID: __________________
ATI No.: _________________________ Amount Collected/Billed: _______________________________
ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant
37A-649 (Revised 06/2020)
State of California
REQUEST FOR LIVE SCAN SERVICE
BCII 8016 (04/2020)
Applicant Submission
APPLICANT
SECTION 1
ORI: A0462
(Code assigned by DOJ)
Type of License: (Mark Only ONE)
Marriage and Family Therapist
Educational Psychologist
Type of Application: LIC/CERT/PERMIT
Clinical Social Worker
Professional Clinical Counselor
SECTION 2
Agency Authorized to Receive Criminal Record
Information:
Board of Behavioral Sciences
1625 North Market Blvd. Suite S-200
Sacramento CA 95834
Mail Code: 01484
Contact Name: Fingerprint Unit
Contact Phone: (916) 574-7859
SECTION 3
Name of Applicant: ______________________________
(Please Print) Last
Alias: _________________________________________
Last First
Date of Birth: ____________ Sex: Male Female
Height: ________________ Weight: _______________
Eye Color: _____________ Hair Color: ____________
Place of Birth: __________________________________
Social Security Number: __________________________
_____________________________ ______
First MI
Driver’s License No.: ____________________
Billing No.: APPLICANT MUST PAY
Address:
______________________________________
Number and Street
________________________ ____ ________
City State Zip
BBS File Number: __________________________
If Resubmission, list Original ATI No.:
_________________________________________
(Must provide proof of rejection)
BBS Applicant: Please mail a copy of this
form to the address in Section 2 with your
BBS application.
Level of Service: DOJ FBI
I have received and read the included Privacy Notice, Privacy Act Statement and Applicant’s Privacy Rights.
Applicant Signature: _____________________________________ Date: __________
SECTION 4
Live Scan Transaction Completed By: ____________________________________ Date: _____________
Transmitting Agency: ___________________________________________ LSID: __________________
ATI No.: _________________________ Amount Collected/Billed: _______________________________
ORIGINAL – Live Scan Operator SECOND COPY – Requesting Agency THIRD COPY - Applicant
37A-649 (Revised 06/2020)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

AND PRIVACY NOTICES INSTRUCTIONS FOR LIVE SCAN FINGERPRINTING (California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document