Laserfiche WebLink
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE <br />c SCIA 9019 PAGE 1 of <br />(Rev. 0112010) <br />REQUEST FOR LIVE SCAN SERVICE <br />Applicant Submission <br />CA0301900 ° PERMIT <br />ORI (code aasignedbyDOU)ARFEnzeApplicant Type <br />REGISTRATION APP. FOR RSP <br />ypeo(cense a Ilcatlon ermli or mg de Mari mum30 charactarsfasslgnad by DOJ. use eaxlll lleassigned <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 />Ity ,,tS ate- o e <br />Other Name <br />(AKA or Alias) ast <br />D. onh r Sex CR-lvriife ❑ Female 1�` � <br />S 1'� g -Cy <br />e" f(J-41\H C <br />egATlit-- el ! o air olor <br />S�- Nt ,ftr k�(Z �-lC('S) `( � <br />Place of Birt (Sete or Country) Social becurity Number <br />Home C a -'A 'S Y <br />Address Street Address or P.O. Box <br />Your Number: <br />OCA Number (Agency Identifying Number) <br />If re -submission, list original ATI number: <br />(Must provide proof of rejection) <br />Employer (Additional response for agencies specified by statute): <br />Employer Name <br />'=-wlr.- <br />Stale ZIP Code <br />Live Scan Transaction Completed By: <br />Grogory A lRarris VUS <br />Name SMNORTH Operator1 <br />GAItl OetRNCxE COIJpiP'( v <br />Transmitting Agency LSID <br />rF-141218PCi <br />man Uccle (rive -digit code assigned by DOJ) __-- <br />A.PEZESHKPOLIR <br />Contact Name (mandatory for all school submissions) <br />(714) 667-2700 <br />Contact Telephone um er <br />Flr`stame T idHfe I'm I'E'aT-- Biu x <br />�Cn �C(C�IBtl1 <br />wer's (cerise umbeV)V r <br />Billing <br />Number <br />(Agency a ng Nu er <br />Misc. <br />Number <br />(Other (dent onion Number) <br />City State ZIP Code <br />Level of Service: ® DOJ ❑ FBI <br />nginal umber <br />Mail e e Iva lgR co a ass gne by <br />Telephone Number (optional) <br />S-fib-zU l g <br />Date <br />ATI Number <br />Amount CollectedlBilled <br />ORIGINAL- Live Scan Operator SECOND COPY � Applicant THIRD COPY (If needed) -Requesting Agency <br />Suffix <br />