INSTRUCTIONS FOR COMPLETING FRONT
1.Code Assigned by DOJ: ORI number pre-printed.
2.Agency Address Set Contributing Agency: Check box “B” if applying for an Ambulance Driver Certificate. Check box “A” for all other licenses, Vehicle Verifier Permit, or Business Partner Automation Program Participant.
3.Type of Application: Check one. Applications for the following type licenses require Live Scan services.
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Ambulance Driver Certificate |
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Driving School Operator License |
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Business Partner Automation Program/Registration |
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Driving School Owner License |
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Service Owner |
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Employer Testing Program Examiner |
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Business Partner Automation Program/Dealer Owner |
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Lessor/Retailer License |
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Business Partner Automation Program/Employee |
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Manufacturer License (includes Remanufacturer) |
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(i.e., Registration Service, Dealer, Automobile Club, |
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Manufacturer Representative License |
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Rental Car, Leasing Company employee). |
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Registration Service License |
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Dealer License |
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Salesperson License |
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Dismantler/Wrecker License |
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Transporter License |
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Distributor License |
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Traffic Viol. School Owner License (includes Operator |
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Distributor Representative License |
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or Instructor) |
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Driving School Instructor License |
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Vehicle Verifier Permit |
4.Name of Applicant: Enter applicant’s full name.
5.AKA: Enter any other names applicant has used.
6.Date of Birth: Enter applicant’s date of birth.
7.Sex: Check the appropriate box for gender: Male, Female, or Nonbinary.
8.Height: Enter applicant’s height.
9.Weight: Enter applicant’s weight.
10.Eye color: Enter applicant’s eye color.
11.Hair color: Enter applicant’s hair color.
12.Place of birth: Enter city, state, and country
13.Social Security Number: Enter applicant’s social security number.
14.California Driver License/Identification Card number: Enter applicant’s California Driver License/Identification Card number.
15.Applicant Pays: Live Scan operator will complete.
16.Miscellaneous Number: Enter other identifying numbers (e.g., other state driver license number).
17.Home Address: Enter applicant’s residence address and telephone number.
18.Your number: DMV identifying number pre-printed.
19.If resubmission: Enter the original ATI number provided on the reject notification to avoid paying an additional processing fee.
20.Level of Service: DOJ required for occupational licenses, in addition, FBI required for Business Partner Automation Program Participants, and employer testing program examiners.
21.Operator Completing Live Scan Transaction: Enter operator’s name.
22.Date: Enter date transaction was completed.
23.Transmitting Agency: Enter live scan identification number.
24.ATI Number: Enter ATI number.
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Amount Collected: Enter amount collected. |
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Print |
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Clear Form |
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Amount Billed: Enter amount billed. |
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