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REQUEST FOR LIVE SCAN SERVICE Applicant Submission CA0349435 (Record Review or Foreign Adoption)

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REQUEST FOR LIVE SCAN SERVICE Applicant Submission CA0349435 (Record Review or Foreign Adoption)
STATE OF CALIFORNIA
BCIA 8016RR
(orig. 04/2001; rev. 10/2014)
DEPARTMENT OF JUSTICE
Page 1 of 2
REQUEST FOR LIVE SCAN SERVICE
(Record Review or Foreign Adoption)
Print Form
Reset Form
Applicant Submission
CA0349435
Type of Application (Check One Only)
ORI (Code assigned by DOJ)
Record Review
Foreign Adoption
Reason for Application
Contributing Agency Information:
DEPARTMENT OF JUSTICE
07041
P.O. BOX 903417
RECORD REVIEW UNIT
Mail Code (five-digit code assigned by DOJ)
Agency Authorized to Receive Criminal Record Information
Street Address or P.O. Box
Contact Name (mandatory for all school submissions)
SACRAMENTO
CA
City
State
94203-4170
ZIP Code
(916) 227-3835
Contact Telephone Number
Applicant Information:
Last Name
Other Name
(AKA or Alias)
First Name
Sex
Date of Birth
Weight
Place of Birth (State or Country)
Male
Eye Color
Female
Hair Color
Social Security Number
Level of Service:
Driver's License Number
Misc. Number (Other Identification Number)
Telephone Number
City
Street Address or P.O. Box
State
ZIP Code
DOJ Only
If re-submission, list original ATI number (Must provide proof of rejection):
Original ATI Number
Foreign Government Embassy: (Mandatory for Foreign Adoption requests pursuant to Penal Code section 11105(c)(12))
Designee -- Do not include Employer: (Optional for individual designated by applicant to Penal Code section 11124)
Designee or Embassy Name
Street Address or P.O. Box
City
State
Country
ZIP Code
Telephone Number
Live Scan Transaction Completed By:
Name of Operator
Transmitting Agency
Date
LSID
ATI Number
ORIGINAL - Live Scan Operator
Suffix
Suffix
First
Last
Height
Middle Initial
SECOND COPY - Applicant
Amount Collected/Billed
STATE OF CALIFORNIA
BCIA 8016RR
(orig. 04/2001; rev. 10/2014)
DEPARTMENT OF JUSTICE
Page 2 of 2
REQUEST FOR LIVE SCAN SERVICE
(Record Review or Foreign Adoption)
Privacy Notice
Collection and Use of Personal Information. The Record Review Unit in the Department of Justice collects the information
requested on this form as authorized by Penal Codes 11121 and 11105(C)(12). The Record Review Unit uses this information
to process applications pertaining to Live Scan service for record review or foreign adoption. In addition, any personal
information collected by state agencies is subject to the limitations in the Information Practices Act and state policy. The
Department of Justice's general privacy policy is available at: http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Access to Your Information. You may review the records maintained by the Record Review Unit in the Department of Justice
that contain your personal information, as permitted by the Information Practices Act. See below for contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan service for record
review or foreign adoption, we may need to share the information you give us with other government agencies.
The information you provide may also be disclosed in the following circumstances:
•
In response to a Public Records Act request, as allowed by the Information Practices Act;
•
To another government agency as required by state or federal law;
•
In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information. For questions about this notice or access to your records, you may contact the Record Review Unit via
telephone at (916) 227-3835 or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Record Review Unit
P.O. Box 903417
Sacramento, CA 94203-4170
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