STATE OF CALIFORNIADEPARTMENT OF JUSTICEBCIABOF 8016 orig 042001 rev - PDF document

1 STATE OF CALIFORNIADEPARTMENT OF JUSTICE
STATE OF CALIFORNIADEPARTMENT OF JUSTICEBCIA/BOF 8016 (orig. 04/2001; rev. 01/2011)PAGE 1 of 1 Applicant Submission ORI (Code assigned by DOJ) Authorized Applicant Type Contributing Agency Information: Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ) Street Address or P.O. Box City ZIP Code Contact Name (mandatory for all school submissions) Contact Telephone Number Applicant Information: Last Name First Name Middle Initial SuffixOther Name (AKA or Alias) Last Suffix Date of BirthSex Driver's License Number Height Eye Color Hair Color Place of Birth (State or Country) Social Security NumberHome Street Address or P.O. Box City ZIP Code Billing (Agency Billing Number) Misc. (Other Identification Number) Your Number:OCA Number (Agency Identifying Number)Level of Service: DOJIf re-submission, list original ATI number: (Must provide proof of rejection) Original ATI Number Employer (Additional response for agencies specified by statute): Employer Name Street Address or P.O. Box City State ZIP Code Mail Code (five digit code assigned by DOJ) Telephone Number (optional) Live Scan Transaction Completed By: Name of Operator Date Transmitting Agency LSID ATI Number Amount Collected/Billed ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency REQUEST FOR LIVE SCAN SERVICE FBI ( NON-SPONSORED 13511.5 PC ) CA94203-0200 916 227-1375DOJ/BUREAU OF FIREARMSP.O. BOX 820200SACRAMENTO94203-0200 xx