Fill - Free fillable Form 06129: REQUEST FOR LIVE SCAN SERVICE (California) PDF form

STATE OF CALIFORNIA

BCIA 8016

(Rev. 04/2020)

DEPARTMENT OF JUSTICE

PAGE 1 of 4

REQUEST FOR LIVE SCAN SERVICE

Applicant Submission

A0023

License

ORI (Code assigned by DOJ)

Authorized Applicant Type

Dental License

Type of License/Certification/Permit OR Working Title (

Maximum 30 characters - if assigned by DOJ, use exact title assigned)

Contributing Agency Information:

Dental Board of California

06129

Agency Authorized to Receive Criminal Record Information

2005 Evergreen Street, Suite 1550

Mail Code (five-digit code assigned by DOJ)

DDS Licensing Unit

Street Address or P.O. Box Contact Name (mandatory for all school submissions)

Sacramento

95815

(916) 263-2300

City State ZIP Code

Contact Telephone Number

Applicant Information:

Last Name

First

Name Middle Initial Suffix

Other Name: (AKA or Alias)

Last Name

First Name

Suffix

Sex

Male Female

Date of Birth

Driver's License Number

Billing

Height

Weight

Hair Color

Number

Eye Color

(Agency Billing Number)

Misc.

Place of Birth (State or Country)

Social Security Number

Number

BIL - APPLICANT TO PAY

(Other Identification Number)

Home

Address

Street Address or P.O. Box

City State ZIP Code

I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.

Applicant Signature

Date

Your Number: DDS

Level of Service:

DOJ FBI

OCA Number (Agency Identifying Number)

(If the Level of Service indicates FBI, the fingerprints will be used to check the

criminal history record information of the 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

Telephone Number (optional)

City State ZIP Code

Mail Code (five digit code assigned by DOJ)

Live Scan Transaction Completed By:

Name of Operator Date

Transmitting Agency LSID ATI Number Amount Collected/Billed

STATE OF CALIFORNIA

BCIA 8016

(Rev. 04/2020)

DEPARTMENT OF JUSTICE

PAGE 2 of 4

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

STATE OF CALIFORNIA

BCIA 8016

(Rev. 04/2020)

DEPARTMENT OF JUSTICE

PAGE 3 of 4

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.

STATE OF CALIFORNIA

BCIA 8016

(Rev. 04/2020)

DEPARTMENT OF JUSTICE

PAGE 4 of 4

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 notification1 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.

• 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.

Written notification includes electronic notification, but excludes oral notification

https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

See 28 CFR 50.12(b)

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)

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