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REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI CA0349400 Type of Application FP ROLLER 11102. 1 PC Code assigned by DOJ FP ROLLER Job Title or Type of License Certification or Permit Agency Address Set Contributing Agency Department of Justice 08354 Agency authorized to receive criminal history information Mail Code five digit code assigned by DOJ P. O. Box 903387 Street No* FRCP Street or P. O. Box Contact Name Mandatory for all school submissions Sacramento CA 94203-3870 City State Zip Code 916 227-6420 Contact Telephone No* Name of Applicant please print Last First Alias MI Driver s License No* Date of Birth Sex Male Female Misc* No* BILAgency Billing Number if applicable Height Hair Color Eye Color Misc* No Home Address Place of Birth City State and Zip Code SOC Your Number Level of Service x DOJ FBI OCA No* Agency Identifying No* If resubmission list Original ATI No* Employer Additional response for agencies specified by statute Employer Name Live Scan Transaction Completed By Agency Telephone No* optional Date Name of Operator Transmitting Agency BCII 8016 Rev 04/01 ORIGINAL Print Form 3 copies needed ATI No* Amount Collected/Billed Live Scan Operator SECOND COPY Requesting Agency THIRD COPY - Applicant Clear Form. 1 PC Code assigned by DOJ FP ROLLER Job Title or Type of License Certification or Permit Agency Address Set Contributing Agency Department of Justice 08354 Agency authorized to receive criminal history information Mail Code five digit code assigned by DOJ P. O. Box 903387 Street No* FRCP Street or P. O. Box Contact Name Mandatory for all school submissions Sacramento CA 94203-3870 City State Zip Code 916 227-6420 Contact Telephone No* Name of Applicant please print Last First Alias MI Driver s License No* Date of Birth Sex Male Female Misc* No* BILAgency Billing Number if applicable Height Hair Color Eye Color Misc* No Home Address Place of Birth City State and Zip Code SOC Your Number Level of Service x DOJ FBI OCA No* Agency Identifying No* If resubmission list Original ATI No* Employer Additional response for agencies specified by statute Employer Name Live Scan Transaction Completed By Agency Telephone No* optional Date Name of Operator Transmitting Agency BCII 8016 Rev 04/01 ORIGINAL Print Form 3 copies needed ATI No* Amount Collected/Billed Live Scan Operator SECOND COPY Requesting Agency THIRD COPY - Applicant Clear Form.

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