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Space

REQUEST FOR LIVE SCAN SERVICE

You have 20 minutes to complete this form
Asterisk (*) indicates a required field
Do not use punctuation marks (commas, periods, slashes, etc.)
Application Type
Space Space Space
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(Code assigned by DOJ)
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Agency Address Set Contributing Agency
Space Space Space Space Space Space Space
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(Agency Name)
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(5 digit code assigned by DOJ)
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(Mandatory for all school submission)
 
   
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Applicant Information
Space Space Space Space Space Space Space
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  * Agency Billing No.:
(If there is no billing information, enter NA. If "Collect All Fees" is printed on your form – enter CAF.)
     
 
   
 
    Home Address
 
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(MM/DD/YYYY)
  
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   Send confirmation email to
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    Confirm Email:
Space Space Space
 
  ONLY required if your ORI is A0448
Space Space Space
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     Required - Click Yes or No
       Required - Click Yes or No