INSTRUCTIONS FOR COMPLETING REQUEST FOR LIVE SCAN SERVICE
APPLICANT SUBMISSION FORM
Be sure to take identification to the live scan site. You must show ID prior to having your
fingerprints taken.
The following information must be printed or typed on the form. All other spaces on the form
should remain blank.
Name of Applicant: Enter your full name.
Alias: Enter any other names you have used.
Date of Birth: You must provide your date of birth in order for the Secretary of State’s Office
to process your background check.
Sex: Gender (male or female)
Height
Weight
Eye Color
Hair Color
Place of Birth
SOC: Social Security Number.
Driver’s License No.: California driver’s license number. If you do not have a California
driver’s license, enter other identifying numbers such as another state driver’s license number
or California ID card number.
Agency Billing No.: Please be prepared to pay the fingerprint processing fee and the rolling
fee at the live scan site (cash, check or money order). Be sure to call the live scan site to
determine the acceptable type of payment and the amount of the required fee.
Agency/OCA No.: Enter your driver’s license number or birth date.
IMPORTANT: Retain one copy of the Request for Live Scan Service form for your records
in case you need to have your prints retaken. This copy will serve as your proof that you have
paid the fingerprint processing fee so you will not be required to pay again. You may,
however, be required to pay for the rolling fee.
X X
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
ORI: A0084 Type of Application:
LICENSE CERT OR PERMIT
Code assigned by DOJ
Job Title or Type of License, Certification or Permit:
NOTARY PUBLIC 8201.1 GC
Agency Address Set Contributing Agency:
CASGSECRETARY OF STATE 03690
Agency authorized to receive criminal history information Mail Code (five digit code assigned by DOJ)
1500 11TH
STREET 2ND
FLOOR
Street No. Street or P.O. Box Contact Name (Mandatory for all school submissions)
SACRAMENTO CA 95814
(
)
City State
Zip Code Contact Telephone No.
Name of Applicant:
(please print)
Last First
MI
Alias: Driver’s License No.
Last First
Date of Birth: SEX:
Male Female Misc. No. BIL -
APPLICANT MUST PAY AT LIVE SCAN SITE
Agency Billing Number
Height: Weight:
Misc. No:
Eye Color: Hair Color: Home Address:
Street or P.O. Box
Place of Birth:
City, State and Zip Code
SOC:
Your Number: Level of Service DOJ FBI
OCA No.
If resubmission, list Original ATI No.
Employer: (Additional response for agencies specified by statute)
Employer Name
Street No. Street or P.O. Box Mail Code (five digit code assigned by DOJ)
( )
City State
Zip Code Agency Telephone No. (optional)
Live Scan Transaction Completed By: Date:
Name of Operator
Transmitting Agency ATI No. Amount Collected/Billed
SOS/BCII 8016 (orig. 4/01; rev. 9/16) ORIGINAL-Live Scan Operator
SECOND COPY-Applicant THIRD COPY (if needed)-Requesting Agency
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome