1. No category

SAMPLE FOR CERTIFICATION OF NURSE ASSISTANTS OR HOME HEALTH AIDES
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
ORI:
A1226
Code assigned by DOJ
Type of Application:
Certification
Job Title or Type of License, Certification, or Permit:
Certified Nurse Assistant (CNA) or Home Health Aide (HHA)
Agency Address Set Contributing Agency:
03314
California Department of Public Health (CDPH)
Mail Code (five-digit code assigned by DOJ)
(leave blank)
Agency authorized to receive criminal history information
Contact Name (Mandatory for all school submissions)
MS 3301, P.O. Box 997416
(
Street or PO Box
95899-7416
Sacramento, CA
City, State
Name of Applicant:
(Please print)
Zip Code
Your full name
Last
AKA's:
Other names known as
DOB:
Date of birth
Last
SEX:
Height
Eye color: Color
POB: Place of birth
First
CDL No.:
First
(Check one)
Male
Female
MI
California Drivers License Number
Misc. No.: BIL -
Weight
Hair color: Color
HT:
WT:
Misc. No.:
Not applicable
Agency Billing Number (if applicable)
Your telephone number
Home Address:
(Applies only if Youth Org/HRA or Public Utility Submission)
Your mailing address
Street or PO Box
Social Security Number:
Your Number:
(leave blank)
)
Contact Telephone No.
*Social Security Number (Required by CDPH)
City, State and Zip Code
*Social Security Number (Required by CDPH)
OCA No. (Agency Identifying No.)
Level of Service
If resubmission, list Original ATI No.
Employer:
DOJ
FBI
(Additional response for Department of Social Services, DMB/CHP licensing, and Department of Corporations submissions only)
(Leave blank)
Employer Name
(Leave blank)
Street No.
Mail Code (five digit code assigned by DOJ)
Street or PO Box
(
City State
Zip Code
Live Scan Transaction Completed By:
Transmitting Agency
Name of Operator
)
Agency Telephone No. (Optional)
Date
ATI No.
Amount Collected/Billed
BCII 8016 (Rev 11/08) SAMPLE
ORIGINAL-Live Scan Operator; SECOND COPY-CDPH; THIRD COPY-Applicant
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.