STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8374
(Orig. 03/2010; Rev. 02/2016)
CUSTODIAN OF RECORDS
APPLICATION FOR CONFIRMATION
(Penal Code section 11102.2)
2.
Applicant Information
Last Name First Name Middle Name
Address City State Zip Code
Phone Number Date of Birth
Driver's License or
CA ID Number
Agency/Organization Information
Agency Head Phone Number
Agency Name ORI Mail Code
Address City State Zip Code
Please answer fully the following questions:
1.
Does the designated Custodian of Records work for the applicant agency?
Yes
No
If yes, what is the relationship?
If no, what is the relationship?
If yes, please list other names below.
Have you ever used a name other than the one on this application?
Yes No
5.
Have you ever been denied a professional license or had such license revoked, suspended, or restricted?
Yes No
If yes, give details below.
6.
Have you ever been adjudged liable for damages in any suit grounded in fraud, misrepresentation, or in violation of state regulatory laws?
Yes No
If yes, give details below.
7.
Have you ever failed to satisfy any court ordered money judgment including restitution?
Yes No
If yes, give details below.
Misrepresentation or Failure to Disclose Requested Information on this Application
Is Cause for Denial or Revocation of Confirmation.
Certification
I certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers, and representations made in the
foregoing application, including all supplementary statements.
Signature of Applicant Date
California Department of Justice
Bureau of Criminal Information and Analysis
Custodian of Records Unit
P.O. Box 903417
Sacramento, CA 94203-4170
DOJ USE ONLY
Date confirmed: Completed by:
Confirmation of Custodian of Records
(initials)
If yes, give details below.
NoYesHave you ever been arrested in California or any other state and/or are you awaiting adjudication for any offense for which you were arrested?
3.
4.
NoYes
Have you ever been convicted by any court of a felony or misdemeanor offense in California or any other state?
If yes, disclose the date and place of arrest, whether the conviction was for a felony or misdemeanor, and the sentence imposed.
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