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Request For Live Scan Service (Board Of Pharmacy) BCII 8016 - California

Request For Live Scan Service (Board Of Pharmacy) Form. This is a California form and can be used in Board Of Pharmacy Statewide .
 Fillable pdf Last Modified 9/26/2011
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STATE OF CALIFORNIA BCII 8016 (orig. 4/01; rev. 6/09) DEPARTMENT OF JUSTICE REQUEST FOR LIVE SCAN SERVICE Applicant Submission A0071 ORI (Code assigned by DOJ) License/Cert/Permit Authorized Applicant Type Pharmacy Wholesaler - Section 4305.5 Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned) Contributing Agency Information: Board of Pharmacy Agency Authorized to Receive Criminal Record Information 05712 Mail Code (five-digit code assigned by DOJ) 1625 N. Market Blvd, Suite N219 Street Address or P.O. Box City Licensing Contact Name (mandatory for all school submissions) Sacramento CA State 95834 ZIP Code (916) 574-7900 Contact Telephone Number Applicant Information: Last Name Other Name (AKA or Alias) Last Date of Birth Height Weight Sex Male Female First Name First Driver's License Number Billing Number (Agency Billing Number) Middle Initial Suffix Suffix Eye Color Hair Color Place of Birth (State or Country) Home Address Social Security Number Misc. Number (Other Identification Number) Street Address or P.O. Box City State ZIP Code Your Number: N/A OCA Number (Agency Identifying Number) Level of Service: DOJ FBI If re-submission, list original ATI number: (Must provide proof of rejection) Employer (Additional response for agencies specified by statute): N/A Employer Name Original ATI Number N/A Mail Code (five digit code assigned by DOJ N/A Street Address or P.O. Box N/A City State ZIP Code Telephone Number (optional) N/A Live Scan Transaction Completed By: Name of Operator Transmitting Agency LSID Date ATI Number SECOND COPY - Applicant Amount Collected/Billed THIRD COPY (if needed) - Requesting Agency American LegalNet, Inc. ORIGINAL - Live Scan Operator
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