Applicant Submission Type of Application Security Guard wFirearmCode assigned by DOJ Job Title or Type of License Certification or Permit Agency Address Set Contributing Agency Bureau of Securi ID: 356192
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�� �� Applicant Submission Type of Application: Security Guard w/Firearm Code assigned by DOJ Job Title or Type of License, Certification or Permit: Agency Address Set Contributing Agency: Bureau of Security & Investigative Services Agency authorized to receive criminal history information 06078 Mail Code (five digit code assigned by DOJ) P.O. BOX 989002 Street or P.O. Box Licensing Contact Name (Mandatory for all school submissions) City Zip Code Contact Telephone No. Name of Applicant: (please print) Sex: First First Female Weight: Eye Color: OCA No. (Agency Identifying No.) If resubmission, list Original ATI No. (Additional response for agencies specified by statute) Employer Name Street or P.O. Box City Zip Code Live Scan Transaction Completed By: Name of Operator Transmitting Agency Driver's License No. Agency Billing Number (if applicable) Home Address: Street or P.O. Box City, State and Zip Code Level of Service Mail Code (five digit code assigned by DOJ) ( ) Agency Telephone No. (optional) Amount Collected/Billed BCII 8016 (Rev 04/01) ORIGINAL - Live Scan Operator, SECOND COPY -Requesting Agency, THIRD COPY -Applicant �� Applicant Submission Type of Application: Security Guard w/Firearm Code assigned by DOJ Job Title or Type of License, Certification or Permit: Agency Address Set Contributing Agency: Bureau of Security & Investigative Services Agency authorized to receive criminal history information 06078 Mail Code (five digit code assigned by DOJ) P.O. BOX 989002 Street or P.O. Box Licensing Contact Name (Mandatory for all school submissions) City Zip Code Contact Telephone No. Name of Applicant: (please print) Sex: First First Female Weight: Eye Color: OCA No. (Agency Identifying No.) If resubmission, list Original ATI No. (Additional response for agencies specified by statute) Employer Name Street or P.O. Box City Zip Code Live Scan Transaction Completed By: Name of Operator Transmitting Agency Driver's License No. Agency Billing Number (if applicable) Home Address: Street or P.O. Box City, State and Zip Code Level of Service Mail Code (five digit code assigned by DOJ) ( ) Agency Telephone No. (optional) Amount Collected/Billed BCII 8016 (Rev 04/01) ORIGINAL - Live Scan Operator, SECOND COPY - Requesting Agency, THIRD COPY - Applicant