Form 41 Ls PDF Details

Delving into the intricacies of the 41 Ls form, a critical component in the live scan fingerprinting process, reveals its importance in a multitude of sectors, from employment to licensing. As a tool requested by the Department of Justice (DOJ), this form serves as a pivot in ensuring that individuals are aptly vetted for positions or licenses that demand a clean criminal history. The form meticulously gathers personal information starting from the applicant's name, including aliases, and extending to more sensitive data like Social Security numbers. Additionally, it specifies the type of application, the job title, or the nature of the license, permit, or certification being sought, aligning the screening process with the requirements designated by contributing agencies. These agencies, tasked with the authorization to receive criminal history information, provide a unique Originating Agency Identifier (ORI) along with their detailed contact information, which anchors the purpose of the background check to specific needs. The form also accommodates details regarding billing, operator conducting the live scan, and the levels of service required, either from the DOJ or FBI, underscoring the comprehensive scope of the background check. Moreover, instructions for resubmission highlight the form’s role in maintaining an ongoing accuracy and relevance of the applicants' records. With slots designated for the employer’s information for statutory specified agencies, the 41 Ls form manifests as a cornerstone in ensuring the safety and integrity of workplaces and public services, underpinning a thorough vetting system crucial for public trust.

QuestionAnswer
Form NameForm 41 Ls
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names41-LS, form 41 ls, BIL, 41 ls form

Form Preview Example

REQUEST FOR LIVE SCAN SERVICE

FORM 41-LS Rev. 07/11

Applicant Submission

ORI:

 

 

 

 

 

 

 

 

 

 

 

 

Type of Application:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code assigned by DOJ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Job Title or Type of License, Certification or Permit:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Address Set Contributing Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency authorized to receive criminal history information

 

 

 

 

Mail Code (five-digit code assigned by DOJ)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street No.

Street or PO Box

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name (Mandatory for all school submissions)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

 

 

 

Zip Code

 

 

 

 

Contact Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Applicant:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please print)

 

Last

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

 

MI

 

 

Alias:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver’s License No:

 

 

 

 

 

 

 

 

 

 

 

Last

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

Sex:

 

 

 

 

Male

 

 

Female

Misc. No. BIL -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Billing Number

 

Height:

 

 

 

 

Weight:

 

 

 

 

 

 

 

 

 

 

 

 

 

Misc. Number:

 

 

 

 

 

 

 

 

 

Eye Color:

 

 

 

Hair Color:

 

 

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street No.

 

 

Street or PO Box

 

Place of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State and Zip Code

 

 

Social Security Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCA No. (Applicant Social Security No.)

 

 

 

 

Level of Service:

 

 

DOJ

 

FBI

 

If resubmission, list Original ATI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer: (Additional response for agencies specified by statute)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street No.

 

Street or PO Box

 

 

 

 

 

 

 

 

 

 

Mail Code (five digit code assigned by DOJ)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

 

Agency Telephone No. (optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Live Scan Transaction Completed By:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Operator

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transmitting Agency

 

 

 

 

 

 

 

 

 

ATI No.

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount Collected/Billed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORIGINAL – Live Scan Operator; SECOND COPY – Applicant; THIRD COPY (if needed) – Requesting Agency

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Write down the data in Date of Birth, Sex, Male, Female Misc No BIL, Height, Weight, Eye Color, Hair Color, Place of Birth, Social Security Number, Your Number, Agency Billing Number, Misc Number, Home Address, and Street No.

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