STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8374
(Orig. 03/2010; Rev. 02/2016)
CUSTODIAN OF RECORDS
APPLICATION FOR CONFIRMATION
(Penal Code section 11102.2)
2.
Applicant Information
Last Name First Name Middle Name
Address City State Zip Code
Phone Number Date of Birth
Driver's License or
CA ID Number
Agency/Organization Information
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?
If yes, please list other names below.
Have you ever used a name other than the one on this application?
Yes No
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.
Misrepresentation or Failure to Disclose Requested Information on this Application
Is Cause for Denial or Revocation of Confirmation.
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
California Department of Justice
Bureau of Criminal Information and Analysis
Custodian of Records Unit
P.O. Box 903417
Sacramento, CA 94203-4170
DOJ USE ONLY
Date confirmed: Completed by:
Confirmation of Custodian of Records
(initials)
If yes, give details below.
NoYesHave you ever been arrested in California or any other state and/or are you awaiting adjudication for any offense for which you were arrested?
3.
4.
NoYes
Have you ever been convicted by any court of a felony or misdemeanor offense in California or any other state?
If yes, disclose the date and place of arrest, whether the conviction was for a felony or misdemeanor, and the sentence imposed.
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STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8374
(Orig. 03/2010) (Rev. 02/2016)
CUSTODIAN OF RECORDS
APPLICATION FOR CONFIRMATION
(Penal Code section 11102.2)
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The Authorization/Custodian of Records (COR) Program in the
Department of Justice collects the information requested on this form as authorized by Penal Code section 11102.2(d).
The COR Program uses this information for the purpose of processing fingerprint-based criminal offender record
information background responses on individuals designated by applicant agencies to serve as Custodian of Records. In
addition, any personal information collected by state agencies is subject to the limitations in the Information Practices Act
and state policy. The Department of Justice'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. This form may
not be processed for failure to provide all personal information requested.
Access to Your Information. You may review the records maintained by the COR Program in the Department of Justice
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 fingerprint-based criminal offender record information
background responses on individuals designated by applicant agencies to serve as COR, we may need to share the
information you give us with other law enforcement or regulatory agencies.
The information you provide may also be disclosed in the following circumstances:
In response to a Public Records Act request, as allowed by the Information Practices Act;
To another government agency as required by state or federal law;
In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information. For questions about this notice or access to your records, you may contact the COR Program by
phone at (916) 227-4815, by e-mail at COR@doj.ca.gov, or via mail at:
California Department of Justice
Bureau of Criminal Information and Analysis
Authorization/Custodian of Records Program
P.O. Box 903417
Sacramento, CA 94203-4170
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