4. Agency Address Set Contributing Agency:
Agency authorized to receive criminal history information:
The following information is pre-printed:
Agency: CA Dept of Social Services Mail Code: 03502
Street No.: P.O. BOX 94244, M.S. 9-15-62 Contact Name: N/A
City, State, Zip: Sacramento, CA 94244-2430 Contact Telephone No.: N/A
5. Applicant Information: Print your full name (last, first, middle initial).
AKA’s: Other names the applicant has used CDL No: CA Drivers License or CA ID
DOB: Date of Birth SEX: Male or Female MISC No: BIL - Enter the agency billing
number, if applicable
HT: Height WT: Weight MISC No.: Enter any other identification numbers
(PERMANENT RESIDENT, OUT OF STATE DRIVER’S LICENSE OR I.D.)
EYE Color: Color of eyes HAIR Color: Color of hair Home Address: Applicant’s home address
POB: State or Country of Birth
SOC: Social Security Number (optional) (See Privacy Statement on Page 4)
6. Facility Number: Enter the facility number or assigned OCA number (Agency Identifying Number).
Level of Service: Preprinted
Note: If a Child Abuse Central Index (CACI) check is required, it will automatically be completed by DOJ
and all applicable fees will be charged. There is no entry necessary on the applicant’s part.
If resubmission for fingerprint quality, list Original Applicant Tracking Information (ATI) No.: If your finger-
prints were rejected and this is a resubmission of your prints, enter the original ATI number provided on the reject
notice to avoid paying an additional processing fee.
7. Employer: Enter the facility name and address for which you are being printed.
Employer Name: Enter the facility/organization name.
Street No.: Enter the facility/organization address.
Mail Code: Enter the facility/organization mail code (if applicable).
City, State, Zip: Enter the facility/organization city, state and zip.
Agency Telephone No.: Enter the facility/organization phone number.
8. Live Scan Transaction Completed By: This section will be completed by the Live Scan operator.
Take two copies of this form with you the day you are fingerprinted. The Live Scan Operator will complete
section 8. One copy will be retained by the Operator and the other you may retain for your records.
LIC 9163 (12/15)
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