REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI:A1500 Type of Application: Process Server Process Server 06126 Mail Code (five digit code assigned by DOJ) _ _ _ _ _ Job Title or Type of License, Certificate or Permit: Agency Address Set Contributing Agency: L.A County RR/CC _ Agency authorized to receive criminal history information 12400 E. Imperial Highway, Room 2001 Street No. City Street or P.O. Box K. Bradley Contact Person Norwalk Ca State 90650 Zip Code (562) 462-2057 Contact Telephone No. Name of Applicant: (Please print) Last First MI _ Alias: _________________________________________ Driver's License No. _________________ Last First Date of Birth:_______________Sex: ____Male ____Female Height:______ Weight:_________ Misc. No: Misc. No. Bil-Customer to Pay Agency Billing Number _ Eye Color:________ Hair Color:_______ Home Address___________________________________ Street or P.O. Box Place of Birth:___________________________ ___________________________________ City, State and Zip Code SOC:__________________________________ Your Number: _____________________________ OCA No. (Agency Identifying No.) Level of Service: X DOJ X FBI If resubmission, list Original ATI No.________________________________ Employer: (Additional response for agencies specified by statute) _________________________________________________________ Employer Name _________________________________________________________ Street Name _______________________________ Mail Code (five digit assigned by DOJ) _________________________________________________________ City State Zip Code _______________________________ Agency telephone No (optional) Live Scan Transaction Completed By:____________________________ Name of Operator Date:_________________ _________________________________ ___________________________ Transmitting Agency ATI No _________________________________________ Amount Collected/Billed ORIGINAL-Live Scan Operator; SECOND COPY-Requesting Agency; THIRD COPY-Applicant American LegalNet, Inc. www.FormsWorkFlow.com