INSTRUCTIONS FOR COMPLETING A "REQUEST FOR LIVE SCAN SERVICE" FORM (California Residents) The following instructions are provided to assist you in completing this form accurately. Please follow all instructions carefully and print clearly; failure to do so may result in processing delays of your application. NOTE TO APPLICANT and LIVE SCAN OPERATOR: The applicant's name, date of birth and US Social Security Number must be entered in at the time of the Live Scan transmission in order for the results to be accepted by the Board of Pharmacy. If any of the applicant's name, date of birth or US Social Security Number are not entered at the time of Live Scan transmission, the applicant may have to have a new Live Scan transmission completed. 1. Job Title or Type of License, Certification, or Permit: Enter the type of license, certification or permit for which you are applying. Appropriate license types include pharmacist, pharmacy technician, intern pharmacist, exemptee, or if an owner or officer of a pharmacy, hospital, clinic, wholesaler or hypodermic permit enter appropriate title of the facility. 2. Name of Applicant: Enter your last name, first name and middle name. Do not use initials or name abbreviations. 3. AKA: Enter all other names you have used, including your maiden name. 4. CDL No: Your California Driver's License Number. 5. DOB: Your date of birth (month/day/year). 6. SEX: Your gender (male or female). 7. HT: Your height in feet and inches. 8. WT: Your weight in pounds. 9. Misc. No.: Enter other identifying numbers. (e.g., Other State Driver's License Number) 10. EYE Color: Color of your eyes 11. HAIR Color: Color of your hair 12. Home Address: Your residence address 13. POB: Enter your place of birth. 14. SOC: Enter your Social Security Number 15. Level of Service: While the Live Scan forms contained in the board's application package are preslugged to indicate level of service at the DOJ and FBI level, please ensure at the time of Live Scan transmission that the Live Scan operator selects both the DOJ and FBI levels of service. If FBI is not selected at the time of original transmission, you may be required to have your Live Scan redone at another time and have to repay for the DOJ and FBI levels of services again. The board has been notified by the DOJ that effective 9/1/07, if the FBI level of service is not requested at the time of original transmission both DOJ and FBI levels of service will have to be redone. Any issue of cost for resubmission should be handled at the Live Scan Site level. Take the completed form to your nearest Live Scan site for fingerprint scanning. There are more than 130 Live Scan sites throughout the state. An up-to-date Live Scan site list is on the Department of Justice's (DOJ) Internet web page at http://ag.ca.gov/fingerprints/publications/contact.htm or call your local police or sheriff's department. Contact the live scan service for hours of operation, an appointment (if necessary), acceptable forms of payment and identification requirements. Be prepared to pay ALL applicable fees (DOJ processing fee of $32, FBI processing fee of $17, and fingerprint scanning service fee) at the time your prints are taken. The live scan fingerprinting service fee varies from about $5 to $20. The cost to electronically submit your fingerprints is determined by the local Live Scan agency and the agency can charge a fee sufficient to recover its costs. The lower portion of the Request for Live Scan Service form must be completed by the live scan operator. The original of the form is retained by the scanning service; the second copy is to be attached to your application and submitted to the board; and the third copy is for your records. FINGERPRINTING AUTHORITY Section 144(b) of the Business and Professions Code authorizes the Board of Pharmacy to require an applicant for licensure to furnish a full set of fingerprints for purposes of conducting criminal history record checks. Fingerprints are required in order for the DOJ/FBI to conduct background checks for criminal convictions. 17M-15 (7-14) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com