DEPARTMENT OF JUSTICE

STATE OF CALIFORNIA BCIA B016 (orig. 04/2001; rev. 01/2011)

REQUEST FOR LIVE SCAN SERVICE Applicant Submission Volunteer

Ak784

Authorized Applicant Type

ORI {Code assigned by DOJ} Type of L1cense/Cert1ficat1on/Perm1t OR Working Title

(Maximum 30 characters - assigned by DOJ, use exact tale assigned}

Contributing Agency Information: California Steam

21270

Agency Authorized to Receive Criminal Record Information

Mail Code (five-digit code assigned by DOJ)

224 Stavros Ct

Scott Rungwerth

Street Address or P.O. Box

Contact Name (mandatory for all school submissions)

Roseville city

CA

95678

(916) 879-6376

State

ZIP Code

Contact Telephone Number

Applicant Information: Last Name

First Name

Other Name (AKA or Alias) Last

First Sex

Date of Birth Height

Weight

Place of Birth (State or Country)

Male

Eye Color

Female

Hair Color

Social Security Number

Middle Initial

Driver's License Number Billing Number

(Agency billing number)

Misc. Number (Other Identification Number)

Home Address

Street Address or P.O. Box

City

State

Level of Service:

Your Number:

X DOJ

ZIP Code

X FBI

OCA Number (Agency Identifying Number)

If re-submission, list original ATI number: (Must provide proof of rejection)

Original ATI Number

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:

Date

Name of Operator Transmitting Agency

LSID

ORIGINAL - Live Scan Operator

ATI Number SECOND COPY - Applicant

Amount Collected/Billed THIRD COPY (if needed) - Requesting Agency