Request for Live Scan Service (BCIA 8016)

Applicant Submission

ORI (Code assigned by DOJ)

Authorized Applicant Type

Type of License/Certification/Permit OR Working Title

Maximum 30 characters (per BCIA 8016).

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

Contact Telephone Number

Applicant Information

Last Name

First Name

Middle Initial

Suffix

Other Name (AKA / Alias)

Other Last Name (AKA/Alias)

Other First Name (AKA/Alias)

Other Suffix (AKA/Alias)

Date of Birth

Sex

Male

Female

Nonbinary/Unspecified

Driver's License Number

Height

Weight

Eye Color

Hair Color

Place of Birth (State or Country)

Social Security Number

Home Address

Street Address or P.O. Box

City

ZIP Code

Billing Number (Agency Billing Number)

Misc. Number (Other Identification Number)

Your Number

OCA Number (Agency Identifying Number)

Level of Service

DOJ

FBI

Original ATI Number (if re-submission)

If re-submission, list original ATI number (must provide proof of rejection).

Employer (if applicable)

Employer Name

Telephone Number (optional)

Street Address or P.O. Box

City

ZIP Code

Mail Code (five digit code assigned by DOJ)

Live Scan Transaction Completed By

Name of Operator

Date

Transmitting Agency

LSID

ATI Number

Amount Collected/Billed

Applicant Acknowledgment

I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.

Applicant Signature