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Open in new tab REQUEST FOR LIVE SCAN SERVICE
FORM 41-LS Rev. 04/15
Applicant Submission
ORI:
A0281
Code assigned by DOJ
Agency Address Set Contributing Agency:
Job Title or Type of License, Certification or Permit:
TEACHER CRED 44340 EC
Type of Application:
License/Certification/Permit
CASM TEACHER CREDENTIALING
Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
03294
Street No.
1900 Capitol Avenue
Street or PO Box
Contact Name (Mandatory for all school submissions)
Sacramento
City
CA
State
95811-4213
Zip Code
Contact Telephone No.
*Name of Applicant:
(Please print)
*Alias:
Last
First
MI
Last
First
*Driver’s L icense No:
*Date of Birth:
*Sex:
Male
Female
–
Misc. No. BIL
Agency Billing Number
*Height:
*Weight:
Misc. Number:
*Home Address:
Street No.
Street or PO Box
City, State and Zip Code
*Social Security Number (full):
* Required Fields
(SSN OR ITIN#)
X
Level of Service:
DOJ
X
FBI
*Eye Color:
*Hair Color:
*Place of Birth:
*OCA Number:
If resubmission, list Original ATI
Number:
SUPPLEMENTAL AGENCY/EMPLOYER
(County Office of Education/School District)
Employer Name
Street No.
Street or PO Box
Mail Code (COE/SD five digit code assigned by DOJ)
City
State
Zip Code
Agency Telephone No. (optional)
Live Scan Transaction Completed By:
Name of Operator
LSID
Date
Transmitting Agency
ATI No.
Amount Collected/Billed
ORIGINAL – Live Scan Operator; SECOND COPY – Applicant; THIRD COPY (if needed) – Requesting Agency