X hits on this document

PDF document

California Department of Public Health - page 3 / 5

13 views

0 shares

0 downloads

0 comments

3 / 5

STATE OF CALIFORNIA BC II 8016 (orig. 4/01; rev. 6/09)

DEPARTMENT OF JUSTICE

SAMPLE FOR HOME HEALTH AGENCY LICENSEE REQUEST FOR LIVE SCAN SERVICE

Applicant Submission

A1226 ORI (Code assigned by DOJ)

Employment or License (Choose one) Authorized Applicant Type

Home Health Agency Licensee Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)

Contributing Agency Information: California Department of Public Health (CDPH)

Agency Authorized to Receive Criminal Record Information

03314 Mail Code (five-digit code assigned by DOJ)

CA

95899-7416

State

Zip Code

MS 3304, P.O. Box 997416 Street Address or P.O. Box

Sacramento City

(Leave blank) Contact Name (mandatory for all school submissions)

(Leave blank) Contact Telephone Number

Applicant Information: Your last name Last Name

Other last names known as Other Name

Your first name & middle initial

First Name Other first names known as

Middle Initial

Suffix

(AKA or Alias) Date of Birth

Last

Sex:

(Check one) Male

Female

Height

Weight

Color

Color

Height

Weight

Eye Color

Hair Color

Place of Birth

*Social Security Number (Required by CDPH)

Place of Birth (State or Country)

Social Security Number

Date of Birth

First Name California Driver's License Number Driver's License Number

Billing Number

Misc. Number

Not Applicable

(Agency Billing Number) Your telephone number

(Other Identification Number)

Suffix

Home Address

Your mailing address Street Address or P.O. Box

City

State

Zip Code

Your Number:

*Social Security Number (Required by CDPH)

Level of Service:

  • DOJ

FBI

OCA Number (Agency Identification Number)

If re-submission, list ATI number: (Must provide proof of Rejection)

Original ATI Number

Employer (Additional response for agencies specified by statute): Facility Name

Employer Name

(Leave blank) Mail Code (five-digit code assigned by DOJ)

Facility Address Street Address or P.O. Box

City

State

Zip Code

Facility Telephone Number Telephone Number (optional)

Live Scan Transaction Completed By:

Name of Operator

Date

Transmitting Agency

LSID

ATI Number

Amount Collected/Billed

BCII 8016 (Rev 07/10) SAMPLE

ORIGINAL - Live Scan Operator

SECOND COPY - Applicant

THIRD COPY (if needed) - Requesting Agency

NOTE TO APPLICANT: *Please input your Social Security Number (SSN) where required. The submission of your SSN will allow results to be transmitted from DOJ to CDPH accurately and timely. Failure to submit your SSN could cause delay in your certification.

Document info
Document views13
Page views13
Page last viewedThu Dec 08 21:36:00 UTC 2016
Pages5
Paragraphs223
Words1543

Comments