STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
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 State 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 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
Home
Address
Street Address or P.O. Box City State ZIP Code
Billing
Number
(Agency Billing Number)
Misc.
Number
(Other Identification Number)
Your 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 State 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
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
Mount Shasta Police Department
