REQUEST FOR LIVE SCAN SERVICE
FORM 41-LS Rev. 04/15
Applicant Submission
ORI:
Code assigned by
DOJ
Type of Application:
Job Titl
e or Type of License, Certif
ication or Permit:
Agency Address Set Contributing Agency:
Agency authorized to receive criminal history information
Street No. Street or PO Box
City State Zip Code
Mail Code (five-digit code assigned by DOJ)
Contact Name (Mandatory for all school submissions)
Contact Telephone No.
*Name of Applicant:
(Please print) Last First MI
*Alias:
Last First
*Date of Birth: *Sex: Male Female -
*Height: *Weight:
*Eye Color: *Hair Color:
*
Place of Birth:
*Social Security Numbe
r (full):
*Dri
ver’s L icense No:
Misc. No. BIL
Agency Billing
Number
Misc. Number:
*Home Address:
Street No. Street or PO Box
City, State and Zip Code
* Required Fields
*OCA Number:
(SSN OR ITIN#)
Level of Service: DOJ X FBI
X
If resubmission, list Original ATI
Number:
SUPPLEMENTAL AGENCY/EMPLOYER
(County Office of Education/School District)
Employer Name
Street
No.
Street
or
PO
Box
City
State
Zip
Code
Mail Code (COE/SD five digit code assigned by DOJ)
Agency
Telephone
No.
(optional)
Live Scan Transaction Completed By:
Name of Operator LSID Date
Transmitting Agency ATI No. Amount Collected/Billed
ORIGINAL – Live Scan Operator; SECOND COPY – Applicant; THIRD COPY (if needed) – Requesting Agency
A0281 License/Certification/Permit
TEACHER CRED 44340 EC
CASM TEACHER CREDENTIALING
03294
1900 Capitol Avenue
Sacramento CA 95811-4213
