STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
CA0010600
LICENSE/PERMIT
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:
HAYWARD POLICE DEPARTMENT
09207
Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)
300 W WINTON AVE
Street Address or P.O. Box
HAYWARD
CA 94544
City State ZIP Code
Applicant Information:
J. WILDMAN
Contact Name (mandatory for all school submissions)
(510) 293-7230
Contact Telephone Number
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias)
Last
First
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
Billing
Number
Misc.
Number
110382
(Agency Billing Number)
(Other Identification Number)
Home
Address Street Address or P.O. Box City
State
ZIP Code
Your Number: CA0010600
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 Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City
State
ZIP Code Telephone Number (optional)
Live Scan Transaction Completed By:
Date
ATI Number
Name of Operator
LSID
Transmitting Agency Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
