ORIGINAL - LIVE SCAN Operator, SECOND COPY - Requesting Agency, THIRD COPY - Applicant STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT REQUEST FOR LIVE SCAN SERVICE APPLICANT SUBMISSION DBO-BDIA 8018 (Rev. 11-18) ORI: A0334 Type of Application: Code assigned by DOJ Job Title or Type of License, Certification, or Permit: Agency Address Set Contributing Agency: DEPARTMENT OF BUSINESS OVERSIGHT 03918 Agency authorized to receive criminal history information Mail Code (five digit code assigned by DOJ) 1515 K STREET, SUITE 200 Street Contact Name SACRAMENTO, CA 95814-4052 (866) 275-2677 City State Zip Code Contact Telephone No. Name of Applicant: Alias: Last * First * MI Driver's License No. Last First Date of Birth:* Sex: Male Female Misc. NO. BIL- Height:* Weight:* Misc. No: Eye Color:* Place of Birth:* Hair Color: Home Address:* Street or P.O. Box SOC:* City, State and Zip Code Your Number: OCA No. (Agency Identifying No.) Level of Service: DOJ FBI If resubmission, list Original ATI No. Employer: (Additional response for agencies specified by statute) Employer Name Street Mail Code (five digit code assigned by DOJ) City State Zip Code Agency Telephone No. (optional) Live Scan Transaction Completed by: Date: Transmitting Agency ATI No. Amount Collected/Billed American LegalNet, Inc. www.FormsWorkFlow.com ORIGINAL - LIVE SCAN Operator, SECOND COPY - Requesting Agency, THIRD COPY - Applicant STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT REQUEST FOR LIVE SCAN SERVICE APPLICANT SUBMISSION DBO-BDIA 8018 (Rev. 11-18) Page 2 of 4 ORI: A0334 Type of Application: Code assigned by DOJ Job Title or Type of License, Certification, or Permit: Agency Address Set Contributing Agency: DEPARTMENT OF BUSINESS OVERSIGHT 03918 Agency authorized to receive criminal history information Mail Code (five digit code assigned by DOJ) 1515 K STREET, SUITE 200 Street Contact Name SACRAMENTO, CA 95814-4052 (866) 275-2677 City State Zip Code Contact Telephone No. Name of Applicant: Alias: Last * First * MI Driver's License No. Last First Date of Birth:* Sex: Male Female Misc. NO. BIL- Height:* Weight:* Misc. No: Eye Color:* Place of Birth:* Hair Color: Home Address:* Street or P.O. Box SOC:* City, State and Zip Code Your Number: OCA No. (Agency Identifying No.) Level of Service: DOJ FBI If resubmission, list Original ATI No. Employer: (Additional response for agencies specified by statute) Employer Name Street Mail Code (five digit code assigned by DOJ) City State Zip Code Agency Telephone No. (optional) Live Scan Transaction Completed by: Date: Transmitting Agency ATI No. Amount Collected/Billed American LegalNet, Inc. www.FormsWorkFlow.com ORIGINAL - LIVE SCAN Operator, SECOND COPY - Requesting Agency, THIRD COPY - Applicant STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT REQUEST FOR LIVE SCAN SERVICE APPLICANT SUBMISSION DBO-BDIA 8018 (Rev. 11-18) Page 3 of 4 c ORI: A0334 Type of Application: Code assigned by DOJ Job Title or Type of License, Certification, or Permit: Agency Address Set Contributing Agency: DEPARTMENT OF BUSINESS OVERSIGHT 03918 Agency authorized to receive criminal history information Mail Code (five digit code assigned by DOJ) 1515 K STREET, SUITE 200 Street Contact Name SACRAMENTO, CA 95814-4052 (866) 275-2677 City State Zip Code Contact Telephone No. Name of Applicant: Alias: Last * First * MI Driver's License No. Last First Date of Birth:* Sex: Male Female Misc. NO. BIL- Height:* Weight:* Misc. No: Eye Color:* Place of Birth:* Hair Color: Home Address:* Street or P.O. Box SOC:* City, State and Zip Code Your Number: OCA No. (Agency Identifying No.) Level of Service: DOJ FBI If resubmission, list Original ATI No. Employer: (Additional response for agencies specified by statute) Employer Name Street Mail Code (five digit code assigned by DOJ) City State Zip Code Agency Telephone No. (optional) Live Scan Transaction Completed by: Date: Transmitting Agency ATI No. Amount Collected/Billed American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT REQUEST FOR LIVE SCAN SERVICE APPLICANT SUBMISSION DBO-BDIA 8018 (Rev. 11-18) Page 4 of 4 DBO Collects and Uses Personal Information: The DBO collects the information requested on this form as authorized by California Code of Regulations (CCR) 260.211 (b)(1)(C)(2). The DBO uses this information to conduct a criminal history record check. Use of the personal Information DBO collects is subject to limitations contained in the Information Practices Act of 1977 and other applicable state and federal laws. Providing Personal Information Is Mandatory: When providing information or documents, please number, or financial information. DBO May Disclose Your Personal Information: We may share your personal information with State and Federal Regulators, and law enforcement agencies. Your personal information may also be disclosed: In response to a Public Records Act request, as allowed by the Information Practices Act. To another governmental agency as required by state or federal law. In response to a court order or administrative order, a subpoena or a search warrant. Your Access to Your Personal Information: You may review the records maintained by DBO that contain your personal information. To request access, contact: DBO Privacy Officer, 1515 K Street, Sacramento, CA 95814, (866) 275-2677. 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