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BCIA 8016
(orig. 04/2001; rev. 01/2011)
Applicant Submission
REQUEST FOR LIVE SCAN SERVICE
DEPARTMENT OF JUSTICE
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
Other Name
(AKA or Alias) Last
Date of Birth
First Name
Middle Initial
Suffix
Suffix
Sex
Male
Female
Driver’s License Number
Height
Weight
Eye Color
Hair Color
Place of Birth (State or Country)
Social Security Number
(Agency Billing Number)
(Other Identification Number)
Home
Address Street Address or P.O. Box
State
ZIP Code
First
Billing
Number
Misc.
Number
City
Your Number: RN #
OCA Number (Agency Identifying Number)
Level of Service:
DOJ
FBI
If re-submission, list original ATI number:
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Original ATI Number
Employer Name
Mail Code (five digit code assigned by DOJ)
City
State
ZIP Code
Telephone Number (optional)
Street Address or P.O. Box
Live Scan Transaction Completed By:
Name of Operator
Transmitting Agency
LSID
Amount Collected/Billed
ORIGINAL – Live Scan Operator
SECOND COPY – Applicant
THIRD COPY (if needed) – Requesting Agency
Date
ATI Number
STATE OF CALIFORNIA
BCIA 8016
(orig. 04/2001; rev. 01/2011)
Applicant Submission
REQUEST FOR LIVE SCAN SERVICE
DEPARTMENT OF JUSTICE
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
Other Name
(AKA or Alias) Last
Date of Birth
First Name
Middle Initial
Suffix
Suffix
Sex
Male
Female
Driver’s License Number
Height
Weight
Eye Color
Hair Color
Place of Birth (State or Country)
Social Security Number
(Agency Billing Number)
(Other Identification Number)
Home
Address Street Address or P.O. Box
State
ZIP Code
First
Billing
Number
Misc.
Number
City
Your Number: RN #
OCA Number (Agency Identifying Number)
Level of Service:
DOJ
FBI
If re-submission, list original ATI number:
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Original ATI Number
Employer Name
Mail Code (five digit code assigned by DOJ)
City
State
ZIP Code
Telephone Number (optional)
Street Address or P.O. Box
Live Scan Transaction Completed By:
Name of Operator
Transmitting Agency
LSID
Amount Collected/Billed
ORIGINAL – Live Scan Operator
SECOND COPY – Applicant
THIRD COPY (if needed) – Requesting Agency
Date
ATI Number
STATE OF CALIFORNIA
BCIA 8016
(orig. 04/2001; rev. 01/2011)
Applicant Submission
REQUEST FOR LIVE SCAN SERVICE
DEPARTMENT OF JUSTICE
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
Other Name
(AKA or Alias) Last
Date of Birth
First Name
Middle Initial
Suffix
Suffix
Sex
Male
Female
Driver’s License Number
Height
Weight
Eye Color
Hair Color
Place of Birth (State or Country)
Social Security Number
(Agency Billing Number)
(Other Identification Number)
Home
Address Street Address or P.O. Box
State
ZIP Code
First
Billing
Number
Misc.
Number
City
Your Number: RN #
OCA Number (Agency Identifying Number)
Level of Service:
DOJ
FBI
If re-submission, list original ATI number:
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Original ATI Number
Employer Name
Mail Code (five digit code assigned by DOJ)
City
State
ZIP Code
Telephone Number (optional)
Street Address or P.O. Box
Live Scan Transaction Completed By:
Name of Operator
Transmitting Agency
LSID
Amount Collected/Billed
ORIGINAL – Live Scan Operator
SECOND COPY – Applicant
THIRD COPY (if needed) – Requesting Agency
Date
ATI Number