Commission of rape or sexual penetration in concert with another person, in violationof Section 264.1;
Continuous sexual abuse of a child, in violation of Section 288.5; Shooting from a vehicle, in violation of subdivision (c) or (d) of Section26100; Intimidation of victims or witnesses, in violation of Section 136.1; Criminal threats, in violation of Section 422;
Any attempt to commit a crime listed in this subdivision other than an assault; Any violation of Section 12022.53;
A violation of subdivision (b) or (c) of Section 11418; and any conspiracy to commit an offense described in this subdivision. If yes, explain.’
1. 2. Does the owner have a conviction for hiring, employing, or using a minor in transporting, carrying, selling, giving away, preparing for sale, or peddling, any controlled substance to a minor; or selling, offering to sell, furnishing, offering to furnish, administering, or giving any controlled substance to a minor? If yes, explain.
3. Does the owner have a felony conviction involving fraud, deceit, or embezzlement? If yes, explain.
October 24, 2023 Regular Meeting of the Lindsay City Council
4. Does the applicant have a felony conviction for drug trafficking with enhancements pursuant to Section 11370.4 or 11379.8 of the Health and Safety Code? If yes, explain.
5. Does the applicant, or any of its officers, directors, or owners, has been subject to fines, penalties, or otherwise been sanctioned for cultivation or production of a controlled substance on public or private lands pursuant to Section 12025 or 12025.1 of the Fish and Game Code?
6. Does the applicant, or any of its officers, directors, or owners, has been sanctioned by a licensing authority or a city, county, or city and county for unauthorized commercial cannabis activities, has had a license suspended or revoked under this division in the three years immediately preceding the date the application is filed with the licensing authority? If yes, explain.
October 24, 2023 Regular Meeting of the Lindsay City Council
7. Failure to obtain and maintain a valid seller’s permit required pursuant to Part 1 (commencing with Section 6001) of Division 2 of the Revenue and Taxation Code. If yes, explain.
8. Are you a member or have you been associated with any criminalstreet gang? If yes, explain.
9. Is there anything else you feel the background investigator should know about you or your experiences?
10. List 5 references that the City may contact.
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
October 24, 2023 Regular Meeting of the Lindsay City Council
Background Investigation Packet – Employee
(Must be completed by each employee)
Under penalty of perjury, I acknowledge that I have personal knowledge of the information stated in this application. I hereby certify that all of the answers provided, and statements made in this questionnaire are true and complete. I understand any misstatements of material fact, omissions, incomplete answers, or inaccurate responses will subject me to disqualification or dismissal.
Employee Name:
Home or Cell Phone:
Home Address:
Date of Birth:
Height:
Weight:
Hair Color:
Signature:
Date:
Items to be completed as part of the Packet at the Lindsay Public Safety Department:
Live Scan (attached)
Photograph (taken at the Lindsay Public Safety
Department) Fingerprinting (done at the Lindsay Public
Safety Department) Copy of Driver’s License, DMV issued ID Card or Passport
Proof of address (DMV-issued ID/driver’s license, and/or recent utility bill under Employee’s name) Staff use only: Pass background check
October 24, 2023 Regular Meeting of the Lindsay City Council
STATE OF CALIFORNIA
BCIA 8016
(Rev. 05/2018)
DEPARTMENT OFJUSTICE
PAGE 24 of
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
CA0540400 NON-SWORN LEA PERSONNEL
ORI (Code assigned by DOJ) Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned) Contributing Agency Information:
LINDSAY POLICE DEPARTMENT 05890
Agency Authorized to Receive CriminalRecord Information Mail Code (five-digit code assigned by DOJ) 185 N. GALE HILL AVE.
Street Address or P.O. Box
LINDSAY
City
Applicant Information:
CA
State
93247
ZIP Code
MARI CARRILLO
Contact Name (mandatory for all school submissions)
(559) 562-7120
Contact Telephone Number
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias) Last First Suffix
Date of Birth Sex Male Female Driver's License Number
Height Weight Eye Color Hair Color
Billing
Number 143059
(Agency Billing Number)
Place of Birth (State or Country) Social Security Number Misc.
Number
(Other Identification Number)
Home
Address Street Address or P.O. Box City State ZIP Code
Your Number:
OCA Number (Agency Identifying Number)
Level of Service: DOJ FBI
(If the Level of Service indicates FBI, the fingerprints will be used to check the criminal history record information of the FBI)
If re-submission, list original ATInumber:
(Must provide proof of rejection) Original ATI Number
Employer (Additional response for agencies specified by statute):
Employer Name Mail Code (five digit code assigned by DOJ) Street Address or P.O. Box
City State ZIP Code Telephone Number (optional)
October 24, 2023 Regular Meeting of the Lindsay City Council
Live Scan Transaction Completed By:
Date
ATI Number
Name of Operator
Transmitting Agency LSID Amount Collected/Billed
October 24, 2023 Regular Meeting of the Lindsay City Council
STATE OF CALIFORNIA
BCIA 8016
(Rev. 05/2018)
DEPARTMENT OFJUSTICE
PAGE 25 of
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS) Division in the Department of Justice (DOJ) collects the information requested on this form as authorized by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and 22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522, 1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112, 17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code sections 9710-9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes and regulations. The CJIS Division uses this information to process requests of authorized entities that want to obtain information as to the existence and content of a record of state or federal convictions to help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for adoption or purposes of a license, certification, or permit. In addition, any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ that contain your personal information, as permitted by the Information Practices Act. See below for contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan service to help determine the suitability of a person applying for a license, employment, or a volunteer position working with children, the elderly, or the disabled, we may need to share the information you give us with authorized applicant agencies.
The information you provide may also be disclosed in the following circumstances:
• With other persons or agencies where necessary to perform their legal duties, and their use of your information is compatible and complies with state law, such as for investigations or for licensing, certification, or regulatory purposes;
• To another government agency as required by state or federallaw.
Contact Information. For questions about this notice or access to your records, you may contact the Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at [email protected], or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
October 24, 2023 Regular Meeting of the Lindsay City Council
Sacramento, CA 94203-4170
October 24, 2023 Regular Meeting of the Lindsay City Council