HomeMy WebLinkAboutacems-request-for-live-scan-service-emt-bcia8016-10-31-2025STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 (Rev. 03/2024)
REQUEST FOR LIVE SCAN SERVICE
PAGE 1 of 4
Applicant Submission
ORI (Code assigned by DOJ)Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box
City ZIP Code
Contact Name (mandatory for all school submissions)
Contact Telephone Number
Applicant Information:
Last Name First Name Middle Initial Suffix
Other Name: (AKA or Alias)
Last Name First Name Suffix
Date of Birth
Sex Male Female Nonbinary/Unspecified Driver's License Number
Height Weight Eye Color Hair Color
Place of Birth (State or Country)Social Security Number
Home
Address Street Address or P.O. Box City ZIP Code
Billing
Number
(Agency Billing Number)Misc.
Number
(Other Identification Number)
Your Number:
OCA Number (Agency Identifying Number)
Level of Service: DOJ FBI
If re-submission, list original ATI
number:
(Must provide proof of rejection)Original ATI Number
Employer (Additional response for agencies specified by statute):
Employer Name
Street Address or P.O. Box
City ZIP Code Mail Code (five digit code assigned by DOJ)
Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
(If the Level of Service indicates FBI, the fingerprints will be used to check
the criminal history record information of the FBI.)
State
State
State
Date
I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.
Applicant Signature
A1958 Emer Med Tech Lic/Cert
RES NO R-2009-471
Alameda County Emergency Medical Services Agency 07337
1000 San Leandro Blvd, #200 Scott Salter
x x
San Leandro CA 94577 510-618-2022
Emergency Medical Services Authority
11120 International Drive, 2nd floor
Rancho Cordova, CA 95670 02531
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 (Rev. 03/2024)
REQUEST FOR LIVE SCAN SERVICE
PAGE 2 of 4
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS) Division in the
Department of Justice (DOJ) collects the information requested on this form as authorized by Business and
Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and 22440-22449; Penal
Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522, 1416.20-1416.50,
1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code sections 8700-87200,
8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112, 17200-17215, and 28122-28124;
Education Code sections 44330-44355; Welfare and Institutions Code sections 9710-9719.5, 14043-14045,
4684-4689.8, and 16500-16523.1; and other various state statutes and regulations. The CJIS Division uses this
information to process requests of authorized entities that want to obtain information as to the existence and
content of a record of state or federal convictions to help determine suitability for employment, or volunteer work
with children, elderly, or disabled; or for adoption or purposes of a license, certification, or permit. In addition, any
personal information collected by state agencies is subject to the limitations in the Information Practices Act and
state policy. The DOJ's general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided. Failure to
provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ that
contain your personal information, as permitted by the Information Practices Act. See below for contact
information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan service to
help determine the suitability of a person applying for a license, employment, or a volunteer position working with
children, the elderly, or the disabled, we may need to share the information you give us with authorized applicant
agencies.
The information you provide may also be disclosed in the following circumstances:
•With other persons or agencies where necessary to perform their legal duties, and their use of your
information is compatible and complies with state law, such as for investigations or for licensing,
certification, or regulatory purposes.
•To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may contact the Associate
Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at
keeperofrecords@doj.ca.gov, or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 (Rev. 03/2024)
REQUEST FOR LIVE SCAN SERVICE
PAGE 3 of 4
Privacy Act Statement
Authority. The FBI's acquisition, preservation, and exchange of fingerprints and associated information is
generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities
include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal
regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may
affect completion or approval of your application.
Principal Purpose. Certain determinations, such as employment, licensing, and security clearances, may be
predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may
be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of
comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its
successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the
employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated
information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may
continue to be compared against other fingerprints submitted to or retained by NGI.
Routine Uses. During the processing of this application and for as long thereafter as your fingerprints and
associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your
consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable
Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI
system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to:
employing, governmental, or authorized non-governmental agencies responsible for employment, contracting,
licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement
agencies; criminal justice agencies; and agencies responsible for national security or public safety.
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 (Rev. 03/2024)
REQUEST FOR LIVE SCAN SERVICE
PAGE 4 of 4
Noncriminal Justice Applicant's Privacy Rights
As an applicant who is the subject of a national fingerprint-based criminal history record check for a
noncriminal justice purpose (such as an application for employment or a license, an immigration or
naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.
• You must be provided written notification1 that your fingerprints will be used to check the
criminal history records of the FBI.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement
when you submit your fingerprints and associated personal information. This Privacy Act
Statement should explain the authority for collecting your information and how your
information will be used, retained, and shared.2
• If you have a criminal history record, the officials making a determination of your
suitability for the employment, license, or other benefit must provide you the opportunity
to complete or challenge the accuracy of the information in the record.
• The officials must advise you that the procedures for obtaining a change, correction, or
update of your criminal history record are set forth at Title 28, Code of Federal
Regulations (CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time
to correct or complete the record (or decline to do so) before the officials deny you the
employment, license, or other benefit based on information in the criminal history record. 3
You have the right to expect that officials receiving the results of the criminal history record check will use it
only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or
executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy
Compact Council. 4
If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for
review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you
may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this
process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks.
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send
your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may
send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that
contributed the questioned information and request the agency to verify or correct the challenged entry. Upon
receipt of an official communication from that agency, the FBI will make any necessary changes/corrections
to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through
16.34.) You can find additional information on the FBI website at https://www.fbi.gov/about-us/cjis/
background-checks.
1 Written notification includes electronic notification, but excludes oral notification
2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3 See 28 CFR 50.12(b)
4 See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)