LIC 9163 – Request For Live Scan Service HR HUB REQUEST FOR LIVE SCAN SERVICEApplicant Submission1. ORI: (Check ✔ one) CCLD A0448 Trustline A1157 Code assigned by DOJ2. Type of Application: (Check ✔ one) Employment License, Certification, Permit Volunteer 3. Job Title or Type of License, Certification or Permit: 4. Agency Address Set Contributing AgencyAgency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ)Street No. Street or PO Box Contact Name (Mandatory for all school submissions)City State Zip Code Contact Telephone No.5. Applicant InformationName of Applicant: First Middle Last (Please print)AKA’s: First Last CDL No. DOB: MM slash DD slash YYYY SEX: Male Female Misc. No. BIL - AGENCY BILLING NUMBER (IF APPLICABLE)HT: WT: Misc. No.: ALIEN REGISTRATION, OUT OF STATE DRIVER’S LICENSE OR I.D.EYE Color: HAIR Color: Home Address:(All applicants must complete)STREET OR PO BOX CITY, STATE AND ZIP CODE 6. Facility DetailsFacility Number: Level of Service DOJ FBI If resubmission (select R2), list Original ATI No. 7. Employer DetailsNOTE: NOT APPLICABLE FOR TRUSTLINE APPLICANTSEmployer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)Employer Name Employer Address Street Address City State / Province / Region ZIP / Postal Code Mail Code (Five digit code assigned by DOJ)Agency Telephone No.(Optional)8. Live Scan TransactionLive Scan Transaction Completed By: Name of OperatorDate MM slash DD slash YYYY Transmitting Agency LSID# ATI No. Amount Collected/BilledPhoneThis field is for validation purposes and should be left unchanged. Subscribe To Our NewsletterReceive Senior Care news and articles. Success! Name Email About You About You I'm a Senior / Family Member of a senior. I'm a Professional who works with seniors and their family members. Subscribe
