Fillable REQUEST FOR LIVE SCAN SERVICE (California)

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REQUEST FOR LIVE SCAN SERVICE (California)

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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 Contact Name (mandatory for all school submissions)
City State ZIP Code
Contact Telephone Number
Applicant Information:
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias)
Last First Suffix
Sex
Male Female
Date of Birth Driver's License Number
Billing
Height Weight Eye Color Hair Color
Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country)
Social Security Number
Number
(Other Identification Number)
Home
Address
Street Address or P.O. Box City State ZIP Code
DOJ
Your Number: RN #
Level of Service:
FBI
OCA Number (Agency Identifying Number)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
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:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
A0391
LICENSE, CERTIFICATION, PERMIT
REGISTERED NURSE LICENSE
BOARD OF REGISTERED NURSING, DCA
05753
PO BOX 944210
ATTN: FINGERPRINT UNIT
SACRAMENTO
CA
94244-2100
FAX TO: (916) 574-8647
APPLICANT PAYS ALL FEES
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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 Contact Name (mandatory for all school submissions)
City State ZIP Code
Contact Telephone Number
Applicant Information:
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias)
Last First Suffix
Sex
Male Female
Date of Birth Driver's License Number
Billing
Height Weight Eye Color Hair Color
Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country)
Social Security Number
Number
(Other Identification Number)
Home
Address
Street Address or P.O. Box City State ZIP Code
DOJ
Your Number: RN #
Level of Service:
FBI
OCA Number (Agency Identifying Number)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
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:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
A0391
LICENSE, CERTIFICATION, PERMIT
REGISTERED NURSE LICENSE
BOARD OF REGISTERED NURSING, DCA
05753
PO BOX 944210
ATTN: FINGERPRINT UNIT
SACRAMENTO
CA
94244-2100
FAX TO: (916) 574-8647
APPLICANT PAYS ALL FEES
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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 Contact Name (mandatory for all school submissions)
City State ZIP Code
Contact Telephone Number
Applicant Information:
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias)
Last First Suffix
Sex
Male Female
Date of Birth Driver's License Number
Billing
Height Weight Eye Color Hair Color
Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country)
Social Security Number
Number
(Other Identification Number)
Home
Address
Street Address or P.O. Box City State ZIP Code
DOJ
Your Number: RN #
Level of Service:
FBI
OCA Number (Agency Identifying Number)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
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:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
A0391
LICENSE, CERTIFICATION, PERMIT
REGISTERED NURSE LICENSE
BOARD OF REGISTERED NURSING, DCA
05753
PO BOX 944210
ATTN: FINGERPRINT UNIT
SACRAMENTO
CA
94244-2100
FAX TO: (916) 574-8647
APPLICANT PAYS ALL FEES
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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REQUEST FOR LIVE SCAN SERVICE (California)

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Completed 6 December 2020

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