Applicant Submission
ORI (Code assigned by DOJ)
Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box
City ZIP Code
Contact Name (mandatory for all school submissions)
Contact Telephone Number
Applicant Information:
Last Name
First Name Middle Initial Suffix
Other Name: (AKA or Alias)
Last Name First Name
Suffix
Date of Birth
Sex
Male Female
Driver's License Number
Height Weight Eye Color Hair Color
Place of Birth (State or Country) Social Security Number
Home
Address
Street Address or P.O. Box City ZIP Code
Billing
Number
(Agency Billing Number)
Misc.
Number
(Other Identification Number)
Your Phone Number:
OCA Number (Agency Identifying Number)
Level of Service:
DOJ FBI
If re-submission, list original ATI number:
(Must provide proof of rejection)
Original ATI Number
Employer (Additional response for agencies specified by statute):
Employer Name
Street Address or P.O. Box
City ZIP Code
Mail Code (five digit code assigned by DOJ)
Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
PAGE 1 of 4
BCIA 8016
(Rev. 04/2020)
REQUEST FOR LIVE SCAN SERVICE
(If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI.)
State
State
State
Date
I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.
Applicant Signature
A1226
Certification
Certified Nurse Assistant-CNA
California Department of Public Health (CDPH)
03314
MS 3301, P.O. Box 997416
Sacramento 95899
Tonya Robinson
(209) 575-6931CA
click to sign
signature
click to edit
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