Fillable Form 24817: REQUEST FOR LIVE SCAN SERVICE (San Bernardino County Assessor-Recorder-Clerk)

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Form 24817: REQUEST FOR LIVE SCAN SERVICE (San Bernardino County Assessor-Recorder-Clerk)

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STATE OF CALIFORNIA
BCIA 8016
(Rev. 05/2018)
DEPARTMENT OF JUSTICE
PAGE 1 of 2
Applicant Submission
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 Contact Name (mandatory for all school submissions)
City
Applicant Information:
State ZIP Code
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
(Agency Billing Number)
(Other Identification Number)
Home
Address
Street Address or P.O. Box City
State ZIP Code
Your Number:
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
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
Transmitting Agency LSID Amount Collected/Billed
REQUEST FOR LIVE SCAN SERVICE
A1489
Process Server (92047)
ORI (Code assigned by DOJ)
Process Server (CB&PC 22351.5)
Assessor-Recorder-Clerk
24817
222 W. Hospitality Lane, 1st Floor
Melissa Garcia
San Bernardino
CA
92415-0022
(855) 732-2575
X X
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
Print Form
Reset Form
STATE OF CALIFORNIA
BCIA 8016
(Rev. 05/2018)
DEPARTMENT OF JUSTICE
PAGE 2 of 2
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Coll
ection 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
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Form 24817: REQUEST FOR LIVE SCAN SERVICE (San Bernardino County Assessor-Recorder-Clerk)

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Completed 31 January 2021

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