Employment - PDF document

1 A0760 Employment GCCCD Employee Grossmon
A0760 Employment GCCCD Employee Grossmont-Cuyamaca Community College District 10856 8800 Grossmont College Dr El Cajon CA 92020-1799 Tim Corcoran (619) 644-7572 Applicant Submission ORI (Code assigned by DOJ) Authorized Applicant Type Type of License/Certification/Permit ORMaximum 30 characters - if assigned by DOJ, use exact title assigned) 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 State ZIP Code Contact Name (mandatory for all school submissions) Contact Telephone Number Applicant Information: First Name Middle Initial SuffixOther Name (AKA or Alias) Last First Suffix Date of BirthSex Male Female Driver's License Number Height Weight Eye Color Hair Color Place of Birth (State or Country) Social Security NumberHome Street Address or P.O. Box City State ZIP Code Billing (Agency Billing Number) Misc. (Other Identification Number) Your Number:OCA Number (Agency Identifying Number)Level of Service: DOJ FBIIf re-submission, list original ATI number: Original ATI Number Employer Name Street Address or P.O. Box City ZIP Code Mail Code (five digit code assigned by DOJ) Telephone Number (optional) 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 STATE OF CALIFORNIADEPARTMENT OF JUSTICE PAGE 1 of 1BCIA 8016 REQUEST FOR LIVE SCAN SERVICE