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Get Cdi Live Scan Request Form Lic 442 39a

State of California Live Scan Service Request Applicant LIC 442-39A Rev. 04/2013 Department of Insurance Attention 1033 Consent Waiver 18 U.S.C. If the applicant completes a 1033 Consent Waiver 18 U.S.C. 1033 that applicant is to make a Third Copy of this form and send it to the California Department of Insurance. 1033 Applicants The California Department of Justice DOJ and Federal Bureau of Investigation s FBI processing fees are to be paid by the license applicant. Be prepared to pay the fees at the time your fingerprints are taken at the license scan service provider site. The applicant is to make two copies of this form and distribute as follows 1 First Copy Original to the Live Scan Provider 2 Second Copy to the Applicant. Part 1 Applicant s Personal Information Please type or print clearly the information below Applicant Name Last First and Middle Former Name/AKA s Last First Date of Birth MM/DD/YYYY Gender Male Female Height Eye Color Hair Color Place of Birth Social Security Number Driver s License Number Daytime Telephone Number Residence Address Street/PO Box City State Zip Code Department and Live Scan Vendor ONLY Part 2 To be completed by Contributing Agency Agency ORI Number Agency Address A0042 Application Type e*g* type of search License Certificate or Permit OCA Number 320 Capitol Mall Sacramento CA 95814 Job Title Insurance Mail Code five-digit code assigned by DOJ 04605 Level of Service California Department of Justice and Federal Bureau of Investigation Part 3 Live Scan Transaction Completed by Name of Date Completed Transmitting Agency operator Amount Collected For rolling fee For DOJ/FBI Processing ATI Number Part 4 Original ATI Number Federal Bureau of Investigation Original - Live Scan operator Second Copy - Requesting Agency Third copy Applicant Terminal ID Resident Producer Licensing Applicant Instructions Step 1 Completion of Live Scan Form The following information must be entered in Part 1 of the form by the applicant Your printed name and former names if any Date of birth gender height weight eye color hair color place of birth social security number SSN driver s license number and Step 2 Producer Fingerprint Requirement One set of classifiable electronic fingerprints is required for every California Department of Insurance CDI applicant unless the applicant is currently licensed or held a CDI license which expired during the last 12 months. Step 3 Fingerprint Services Live Scan Fingerprint Services available in California The California Department of Justice DOJ maintains a listing of Live Scan fingerprinting services available to the public* The DOJ list is broken down by county. Fees vary from location to location* Applicants are encouraged to contact the Live Scan provider in advance to verify their current operating hours fees etc* This list is available at the following website http //ag. ca*gov/fingerprints/publications/contact. php For your convenience CDI s contracted vendor Accurate Biometrics will have staff available at the CDI s examination sites to complete the fingerprint impression requirement.

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