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)
Agency Authorized to Receive Criminal Record Information
Contributing Agency Information:
Street Address or P.O. Box
City Zip Code
State
Contact Name (mandatory for all school submissions)
Mail Code (five-digit code assigned by DOJ)
Contact Telephone Number
Applicant Information:
Last Name
Last
Other Name
(AKA or Alias)
Date of Birth
First Name Middle Initial
Suffix
First Name
Suffix
Driver's License Number
Height
Weight
Eye Color
Hair Color
Place of Birth (State or Country)
Social Security Number
(Agency Billing Number)
Billing
Number
(Other Identification Number)
Misc.
Number
Street Address or P.O. Box
Home
Address
Zip Code
City
State
Male Female
Sex:
Your Number:
OCA Number (Agency Identification Number)
DOJ FBI
Level of Service:
Original ATI Number
If re-submission, list ATI number:
(Must provide proof of Rejection)
State
Employer Name
Employer (Additional response for agencies specified by statute):
Street Address or P.O. Box
City Zip Code
Mail Code (five-digit code assigned by DOJ)
Telephone Number (optional)
Name of Operator
Live Scan Transaction Completed By:
Transmitting Agency LSID
Date
ATI Number
Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
REQUEST FOR LIVE SCAN SERVICE
STATE OF CALIFORNIA
BC II 8016
(orig. 4/01; rev. 6/09)
DEPARTMENT OF JUSTICE
(Check one)
NOTE TO APPLICANT: *Please input your Social Security Number (SSN) where required. The submission of your SSN will allow results to
be transmitted from DOJ to CDPH accurately and timely. Failure to submit your SSN could cause delay in your certification.
BCII 8016 (Rev 07/10) SAMPLE
SAMPLE FOR CERTIFICATION OF NURSE ASSISTANTS OR HOME HEALTH AIDES
