DUAL REPORTING
Request for Livescan Service
Applicant Submission
A1270
ORI:
DUAL REPORTING
Request for Livescan Service
Applicant Submission
TCC/TEACHER CREDENTIALING
Type of Application:
A1270
ORI:
Code assigned by DOJ
TCC/TEACHER CREDENTIALING
Type of Application:
Code assigned by DOJ
Substitute Teacher
Job TItle or Type of License, Certificate or Permit:
Contributing Agency:
Substitute Teacher
Job TItle or Type of License, Certificate or Permit:
04166
Contributing Agency:
04166
Mail Code (five-digit code assigned by DOJ)
SAN DIEGO COUNTY OFFICE OF EDUCATION
6401 Linda Vista Rd., Room #404A - Credential Dept
San Diego, CA 92111-7399
Email: [email protected]
Name of Applicant
Last CREDENTIALS DEPARTMENT
Contact Name (Manadary for all school submissions)
CREDENTIALS DEPARTMENT
Contact Name (Manadary for all school submissions)
858-292-3581
Contact Telephone No.
Email: [email protected]
858-292-3581
Contact Telephone No.
First
Alias:
Last First
Driver’s License No.:
Date of Birth:
Misc, No. BIL-
Sex:q Male q Female
Height:
Weight:
Eye/Color:
Hair/Color:
Name of Applicant
MI
N/A
Agency Billing Number
Phone No.
Mail Code (five-digit code assigned by DOJ)
SAN DIEGO COUNTY OFFICE OF EDUCATION
6401 Linda Vista Rd., Room #404A - Credential Dept
San Diego, CA 92111-7399
Place of Birth:
City, State and Zip Code
SS#:
First
Driver’s License No.:
Date of Birth:
Misc, No. BIL-
Sex:q Male q Female
Weight:
Eye/Color:
Street or P.O. Box
Last Alias:
Last First
Height:
Home Address:
N/A
Agency Billing Number
Hair/Color:
Phone No.
Home Address:
Street or P.O. Box
Place of Birth:
City, State and Zip Code
SS#:
Your Number:
OCA No. (Applicant SS #)
x DOJ
Level of Service: q
x FBI
q
Your Number:
OCA No. (Applicant SS #)
x DOJ
Level of Service: q
If resubmission, list Origianl ATI No.
If resubmission, list Origianl ATI No.
Employer: (additional responses for agencies specified by statute)
Employer: (additional responses for agencies specified by statute)
Employer Name
Employer Name
Street No.
City
MI
Street or P.O. Box
State
Zip Code
Mail Code (five digit code assigned by DOJ)
Street No.
(
)
Agency Telephone No. (optional)
City
Street or P.O. Box
State
Zip Code
x FBI
q
Mail Code (five digit code assigned by DOJ)
(
)
Agency Telephone No. (optional)
Live Scan Transaction Completed By:
Date: _________________
Name of Operator
Live Scan Transaction Completed By:
Date: _________________
Name of Operator
Transmitting Agency
BCII 8016 (Rev 3/07)
SDCOE/CCTC
ORIGINAL–Livescan Operator
ATI No. SECOND COPY – Requesting Agency
Amount Collected/Billed
THIRD COPY – Applicant
FOURTH Copy - Additional
Transmitting Agency
BCII 8016 (Rev 3/07)
SDCOE/CCTC
ORIGINAL–Livescan Operator
ATI No. SECOND COPY – Requesting Agency
Amount Collected/Billed
THIRD COPY – Applicant
FOURTH Copy - Additional