REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI: A0071 Type of Application: Code assigned by DOJ Job Title or Type of License, Certification or Permit: (check one) Employment License, Certification, Permit Volunteer Pharmacy Wholesaler - Section 4305.5 (See instruction sheet for appropriate license types) Agency Address Set Contributing Agency: 05712 Board of Pharmacy Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ) Licensing 1625 N. Market Blvd, Suite N219 Street No. Street or PO Box Contact Name (Mandatory for all school submissions) Sacramento, CA 95834 ( 916 City State 574-7900 ) Zip Code Contact Telephone No. Name of Applicant: (Please print) Last First Middle CDL No. AKA’s: Last California Driver's License Number First SEX: DOB: Male Female Agency Billing Number (if applicable) WT: HT: Height EYE Color: Misc. No. Other State Driver's License Number Weight HAIR Color: POB: Applicant Must Pay Fees Misc. No. BIL - Date of Birth Home Address: Street or PO Box Place of Birth SOC: City, State and Zip Code Social Security Number Your Number: N/A OCA No. (Agency Identifying No.) Level of Service DOJ FBI If resubmission, list Original ATI No. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only) N/A Employer Name N/A N/A Street No. Street or PO Box Mail Code (five digit code assigned by DOJ) N/A City ( State Zip Code N/A ) Agency Telephone No. (Optional) Date Live Scan Transaction Completed By: Name of Operator Transmitting Agency BCII 016 (rV 10/98) ATI No. Amount Collected/Billed ORIGINAL-Live Scan Operator; SECOND COPY-Board of Pharmacy; THIRD COPY-Applicant ORIGINAL American LegalNet, Inc. www.FormsWorkflow.com REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI: A0071 Type of Application: Code assigned by DOJ Job Title or Type of License, Certification or Permit: (check one) Employment License, Certification, Permit Volunteer Pharmacy Wholesaler - Section 4305.5 (See instruction sheet for appropriate license types) Agency Address Set Contributing Agency: Board of Pharmacy 05712 Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ) Licensing 1625 N. Market Blvd, Suite N219 Street No. Street or PO Box Contact Name (Mandatory for all school submissions) Sacramento, CA 95834 ( City State 916 ) 574-7900 Zip Code Contact Telephone No. Name of Applicant: (Please print) Last First Middle CDL No. AKA’s: Last First SEX: DOB: Male California Driver's License Number Female Agency Billing Number (if applicable) WT: HT: Height EYE Color: Applicant Must Pay Fees Misc. No. BIL - Date of Birth Misc. No. Weight Other State Driver's License Number HAIR Color: Home Address: POB: Street or PO Box Place of Birth SOC: City, State and Zip Code Social Security Number Your Number: N/A OCA No. (Agency Identifying No.) Level of Service DOJ FBI If resubmission, list Original ATI No. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only) N/A Employer Name N/A N/A Street No. Street or PO Box Mail Code (five digit code assigned by DOJ) N/A City ( State Zip Code N/A ) Agency Telephone No. (Optional) Date Live Scan Transaction Completed By: Name of Operator Transmitting Agency BCII 016 (Rev 10/98) ATI No. Amount Collected/Billed ORIGINAL-Live Scan Operator; SECOND COPY - Board of Pharmacy; THIRD COPY-Applicant SECOND COPY American LegalNet, Inc. www.FormsWorkflow.com REQUEST FOR LIVE SCAN SERVICE Applicant Submission ORI: A0071 Type of Application: Code assigned by DOJ Job Title or Type of License, Certification or Permit: (check one) Employment License, Certification, Permit Volunteer Pharmacy Wholesaler - Section 4305.5 (See instruction sheet for appropriate license types) Agency Address Set Contributing Agency: Board of Pharmacy 05712 Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ) Licensing 1625 N. Market Blvd, Suite N219 Street No. Street or PO Box Contact Name (Mandatory for all school submissions) Sacramento, CA 95834 ( 916 City State ) 574-7900 Zip Code Contact Telephone No. Name of Applicant: (Please print) Last First Middle CDL No. AKA’s: Last First SEX: DOB: Male California Driver's License Number Female Agency Billing Number (if applicable) WT: HT: Height EYE Color: Applicant Must Pay Fees Misc. No. BIL - Date of Birth Misc. No. Weight Other State Driver's License Number HAIR Color: Home Address: POB: Street or PO Box Place of Birth SOC: City, State and Zip Code Social Security Number Your Number: N/A OCA No. (Agency Identifying No.) Level of Service DOJ FBI If resubmission, list Original ATI No. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only) N/A Employer Name N/A N/A Street No. Street or PO Box Mail Code (five digit code assigned by DOJ) N/A City ( State Zip Code N/A ) Agency Telephone No. (Optional) Date Live Scan Transaction Completed By: Name of Operator Transmitting Agency BCII 016 (Rev 10/98) ATI No. Amount Collected/Billed ORIGINAL-Live Scan Operator; SECOND COPY - Board of Pharmacy; THIRD COPY - Applicant THIRD COPY American LegalNet, Inc. www.FormsWorkflow.com