Request For Live Scan
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 04/2001; rev. 01/2011)
REQUEST FOR LIVE SCAN SERVICE
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
Other Name
(AKA or Alias) Last
Sex Male FemaleDate of Birth
Height Weight Eye Color Hair Color
Place of Birth (State or Country) Social Security Number
Home
Address Street Address or P.O. Box
First Name Middle Initial Suffix
First Suffix
Driver's License Number
Billing
Number
(Agency Billing Number)
Misc.
Number
(Other Identification Number)
City State ZIP Code
DOJ FBILevel of Service:Your Number:
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
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency