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Instructions For Completing A Request For Live Scan Service Form (California Residents) 17M-15 - California
| Instructions For Completing A Request For Live Scan Service Form (California Residents) Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
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INSTRUCTIONS FOR COMPLETING A "REQUEST FOR LIVE SCAN SERVICE" FORM (California Residents) The following instructions are provided to assist you in completing this form accurately. Please follow all instructions carefully and print clearly; failure to do so may result in processing delays of your application. NOTE TO APPLICANT and LIVE SCAN OPERATOR: The applicant's name, date of birth, and US social security number must be entered in at the time of the Live Scan transmission in order for the results to be accepted by the Board of Pharmacy. If any of the required information indicated below is not entered at the time of Live Scan transmission, the applicant may be required to have a new Live Scan transmission completed. REQUIRED INFORMATION Type of License/Certification/Permit OR Working Title: It is important that you print out the Live Scan form that goes with your application, as this information is already entered on the form for you. It is important that the Live Scan operator types in this information exactly into their system or at least the numeric section. Name: Enter your name as it appears on your U.S. government photo identification (ID). The name on your ID must match identically to the name you enter on your application. If you change your name, you are required to notify the board within 30 days of the change. Other Name (AKA): Enter all other names you have used, including your maiden name. Date of Birth: (month/day/year). SEX: Mark the appropriate gender box (male or female) Driver's License Number: California Driver's License Number. Height: Your height in feet and inches. Weight: Your weight in pounds. Eye Color: Color of your eyes Hair Color: Color of your hair Place of Birth: Enter your place of birth Social Security Number (Mandatory): Enter your US Social Security Number Misc. Number: Other identification number Home Address: Your residence address Level of Service: While the Live Scan forms contained in the board's application package are pre-slugged to indicate level of service at the DOJ and FBI level, please ensure at the time of Live Scan transmission that the Live Scan operator selects both the DOJ and FBI levels of service. If FBI is not selected at the time of original transmission, you may be required to have your Live Scan redone at another time and have to repay for the DOJ and FBI levels of services again. The board has been notified by the DOJ that effective 9/1/07; if the FBI level of service is not requested at the time of original transmission both DOJ and FBI levels of service will have to be redone. Any issue of cost for resubmission should be handled at the Live Scan Site level. Take the completed form to your nearest Live Scan site for fingerprint scanning. There are more than 130 Live Scan sites throughout the state. An up-to-date Live Scan site list is on the Department of Justice's (DOJ) Internet web page at http://ag.ca.gov/fingerprints/publications/contact.htm or call your local police or sheriff's department. Contact the live scan service for hours of operation, an appointment (if necessary), acceptable forms of payment and identification requirements. Be prepared to pay ALL applicable fees (DOJ processing fee of $32, FBI processing fee of $19, and fingerprint scanning service fee) at the time your prints are taken. The live scan fingerprinting service fee varies from about $5 to $20. The cost to electronically submit your fingerprints is determined by the local Live Scan agency and the agency can charge a fee sufficient to recover its costs. The lower portion of the Request for Live Scan Service form must be completed by the live scan operator. Please print three copies of the Request for Live Scan Service form. The original of the form is retained by the scanning service; the second copy is to be attached to your application and submitted to the board; and the third copy is for your records. FINGERPRINTING AUTHORITY Section 144(b) of the Business and Professions Code authorizes the Board of Pharmacy to require an applicant for licensure to furnish a full set of fingerprints for purposes of conducting criminal history record checks. Fingerprints are required in order for the DOJ/FBI to conduct background checks for criminal convictions. 17M-15 (811) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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