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STATE OF CALIFORNIA <br />SCIA 8016 <br />(ftov. 01/2018) <br />v' S <br />a&vmrar <br />Submission <br />CA0301900 <br />ORI (Code assigned by <br />PERMIT <br />Aufffi—onze�licant Type <br />REGISTRATION APP. FOR RSP <br />Type of icense ertl cation ermlt OR VVOrRlng Ite Me%imoma0cnaractem-gassigmdby DOJ.umexwttideaesigned <br />Contributing Agency Information: <br />SANTA ANA POLICE DEPARTMENT <br />Agency Authorized to Receive Criminal Record Information <br />60 CIVIC CENTER PLAZA <br />Street Address or P.O. Box <br />SANTA ANA CA 92702 <br />Cityiste -o e <br />A06020 <br />Mail o e (five - digit code assign ) <br />A.PEZESHKPOUR <br />Contact Name (mandatory for all school submissions) <br />(714) 667-2700 <br />Contact Telephone Number <br />DEPARTMENT OF JUSTICE <br />PAGE 1 of 2 <br />Applicant Information: <br />} � �Icy) Q <br />Last a eMrs ame -'Middle Initial UTfix <br />Other Name <br />(AKAor Alias) Lear <br />bat> Sex <br />elg�___•_ Qlght <br />� <br />! y O <br />Place of Birth (State or Country) <br />Male Female <br />(Az P, Bb n�v <br />Eye or air o or <br />ZN5 ` a -r (0403 <br />Social Security Number <br />Home 21570 QJ `✓tiJG.Stn/ u V\k� * 1 S <br />Address Street Address or P.O. Bou <br />Your Number: <br />OCA Number (Agency identirying Number) <br />First Suffix <br />(�-c:)s - d3)� <br />r'6iverls License Number <br />Billing <br />Number <br />(AganoV ailing Nu er) <br />Misc. <br />Number <br />(Other Idenllacadon Number) <br />OviG pacl,-,t <br />City U Stats ZIP Code <br />Level of Service: ❑X DOJ E] FBI <br />If re -submission, list original ATI number: Original umber <br />(Must provide proof of rejection) <br />Employer (Additional response for agencies specified by statute) <br />W�- �'aXZ --`fvQ-)as <br />Employer Name <br />loc �2oaclt�kx <br />S or H.Lt. box <br />Loh c� <br />City State ZIP Code <br />Live Scan Transaction Completed By: <br />Mail o e (five digit code ass gne by ) <br />Telephone Number (optional) <br />GregoryAHarris VUS 5-p&-2c)t 5 <br />Name of Operator Date ✓� / - / �� <br />fldYE,SCAN NORLN 0WG9 0WN7y \�4- <br />6 /V d 7�1 WY BV iJ® <br />Transmitting Agency LSID ATI Number Amount CollecledlBilled <br />ORIGINAL• Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed)- Requesting Agency <br />