Authorization School Form

California Department of Justice
Application Package for Authorization

Application for Authorization Pursuant to Education Code 33192, 33195.3 and 45125.1 (School Contractors)

Authorization for Criminal History Information

In accordance with California Education Code Sections 33192, 33195.3 and 45125.1, a school district, heritage school or private school may require an entity that has an existing contract with a district/heritiage/private school to obtain a criminal history clearance.

1. Access is granted only to the primary contractor (there is no authority for subcontractors to gain direct access to Department of Justice records).

2. Services provided under contract must be performed on school grounds.

3. The entity must have a contract (entities in the bid process are not authorized).

4. Completed applications for authorization must have original signatures only.

Request for Authorization to Receive State Summary Criminal History Information - Contract Employee for Public/Heritage Private Schools

Name of Contractor:

Mailing Address:

City, State, Zip Code:

Phone Number: Facsimile Number:

Printed Name: Title:

Signature: Date:

School District/County Office of Education/Heritage or Private School Background Check Requirement Verification

1. Name of Contracting School District Or Heritage/Private School

2. Signature of School Official

3. Phone and Fax Number

Request for Contributing Agency ORI and/or Response Mail Code

Contributing Agency Name:

Mailing Address:

City, State, Zip Code:

Your projection for monthly applicant submissions:

Contact Person Name: Phone Number:

Please check the box(es) for the type(s) of applicants for whom you will be submitting:

Employment

License, Certification, Permit

Volunteers

We request that all responses be sent electronically to the same secure mailbox.

We request separate secure mailbox(es) for the following application type(s):

Employment

License, Certification, Permit

Volunteers

Notification of ORI, Mail Code, and/or Billing Number

Contributing Agency Name:

Mailing Address:

City, State, Zip Code:

ORI: Mail Code: Billing Number:

Billing Account Application

Contributing Agency Name:

Mailing Address:

City, State, Zip Code:

Federal Tax Identification Number:

Social Security Number (Sole Proprietorship or Partnership):

Authorized Representative:

Telephone Number: Facsimile Number:

Electronic Mail Address:

Signature Printed Name

Title Date

Applicant Fingerprint Response Subscriber Agreement

Contributing Agency/Organization Name:

Mailing Address:

City, State, Zip Code:

Phone Number:

Signature of Agency Official:

Printed Name of Agency Official:

Title of Agency Official:

Date:

Criminal Offender Record Information Policy

Contributing Agency/Organization Name:

Mailing Address:

City, State, Zip Code:

Physical Address:

Signature: Date:

Print Name: Title:

Custodian of Records Application for Confirmation

Last Name: First Name: Middle Name:

Address: City: State: Zip Code:

Phone Number: Date of Birth: Driver's License or CA ID Number:

Agency Head: Phone Number:

Agency Name: ORI: Mail Code:

Address: City: State: Zip Code:

Please answer fully the following questions:

1. Does the designated Custodian of Records work for the applicant agency? Yes No

If yes, what is the relationship?

If no, what is the relationship?

2. Have you ever used a name other than the one on this application? Yes No

If yes, please list other names below:

3. Have you ever been convicted by any court of a felony or misdemeanor offense in California or any other state? Yes No

If yes, disclose the date and place of arrest, whether the conviction was for a felony or misdemeanor, and the sentence imposed.

4. Have you ever been arrested in California or any other state and/or are you awaiting adjudication for any offense for which you were arrested? Yes No

If yes, give details below:

5. Have you ever been denied a professional license or had such license revoked, suspended, or restricted? Yes No

If yes, give details below:

6. Have you ever been adjudged liable for damages in any suit grounded in fraud, misrepresentation, or in violation of state regulatory laws? Yes No

If yes, give details below:

7. Have you ever failed to satisfy any court ordered money judgment including restitution? Yes No

If yes, give details below:

Certification

I certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers, and representations made in the foregoing application, including all supplementary statements.

Signature of Applicant: Date:

Request for Live Scan Service (Custodian of Records)

ORI (Code assigned by DOJ): Authorized Applicant Type:

Type of License/Certification/Permit OR Working Title:

Agency Authorized to Receive Criminal Record Information:

Street Address or P.O. Box: City: State: ZIP Code:

Contact Name (mandatory for all school submissions): Contact Telephone Number:

Last Name: First Name: Middle Initial: Suffix:

Other Name (AKA or Alias): Date of Birth: Sex: Male Female

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: State: ZIP Code:

Your Number (OCA Number): Level of Service: DOJ FBI

Original ATI Number:

Employer Name: Mail Code:

Employer Street Address or P.O. Box: Telephone Number (optional):

Name of Operator: Date:

Transmitting Agency: LSID: ATI Number: Amount Collected/Billed:

Contract for Subsequent Arrest Notification Service

Agency Name:

Agency Address:

City: State: ZIP Code:

ORI Number:

Contact Person(s): Contact Person(s) Telephone:

Please retain the following authorized categories:

All Employees

All Volunteers

All Licenses, Certifications, or Permits

Other (specify)

Signature of Agency Representative: Date:

Print Name: Title of Agency Representative:

Employee Statement

As an employee/volunteer of:

Contributing Agency/Organization Name:

Signature: Date:

Print Name: Title:

Contributing Agency/Organization Name:

No Longer Interested Notification

California Penal Code section 11105.2(d) states that any agency which submits the fingerprints of applicants for employment or approval to the DOJ shall immediately notify the Department when employment is terminated or the applicant is not hired.

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