INSTRUCTIONS FOR COMPLETING REQUEST FOR LIVE SCAN SERVICE APPLICANT SUBMISSION FORM Be sure to take identification to the live scan site. You must show ID prior to having your fingerprints taken. The following information must be printed or typed on the form. All other spaces on the form should remain blank. Name of Applicant: Enter your full name. Alias: Enter any other names you have used. Date of Birth: You must provide your date of birth in order for the Secretary of State's Office to process your background check. Sex: Gender (male or female) Height Weight Eye Color Hair Color Place of Birth SOC: Social Security Number. Driver's License No.: California driver's license number. If you do not have a California driver's license, enter other identifying numbers such as another state driver's license number or California ID card number. Agency Billing No.: Please be prepared to pay the fingerprint processing fee and the rolling fee at the live scan site (cash, check or money order). Be sure to call the live scan site to determine the acceptable type of payment and the amount of the required fee. Agency/OCA No.: Enter your driver's license number or birth date. IMPORTANT: Retain one copy of the Request for Live Scan Service form for your records in case you need to have your prints retaken. This copy will serve as your proof that you have paid the fingerprint processing fee so you will not be required to pay again. You may, however, be required to pay for the rolling fee. American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI: A0084 Code assigned by DOJ Type of Application: LICENSE CERT OR PERMIT NOTARY PUBLIC 8201.1 GC Job Title or Type of License, Certification or Permit: Agency Address Set Contributing Agency: CASGSECRETARY OF STATE Agency authorized to receive criminal history information 03690 Mail Code (five digit code assigned by DOJ) 1500 11TH STREET 2ND FLOOR Street No. Street or P.O. Box Contact Name (Mandatory for all school submissions) SACRAMENTO City CA State 95814 Zip Code ( ) Contact Telephone No. Name of Applicant: (please print) Last First MI Alias: Last Date of Birth: First Driver's License No. SEX: Male Female Misc. No. BIL - APPLICANT MUST PAY AT LIVE SCAN SITE Agency Billing Number Height: Eye Color: Place of Birth: Weight: Hair Color: Misc. No: Home Address: Street or P.O. Box City, State and Zip Code SOC: Your Number: OCA 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 No. Street or P.O. Box Mail Code (five digit code assigned by DOJ) ( City State Zip Code ) Agency Telephone No. (optional) Live Scan Transaction Completed By: Name of Operator Date: Transmitting Agency ATI No. SECOND COPY-Applicant Amount Collected/Billed THIRD COPY (if needed)-Requesting Agency American LegalNet, Inc. www.FormsWorkFlow.com SOS/BCII 8016 (orig. 4/01; rev. 9/16) ORIGINAL-Live Scan Operator