REQUEST FOR LIVE SCAN SERVICE Applicant …

1 7. NOTE: NOT APPLICABLE FOR TRUSTLINE APPLICANTSE mployer: (Additional response for Department of Social services , DMV/CHP licensing, and Department of Corporations submissions only)Employer NameStreet No. Street or PO BoxMail Code (five digit code assigned by DOJ)City State Zip CodeAgency Telephone No. (Optional)4. Agency Address Set Contributing Agency:Agency authorized to receive criminal history informationMail Code(five-digit code assigned by DOJ)Street or PO BoxContact Name(Mandatory for all school submissions)CityState Zip CodeContact Telephone Type of Application: (Check one) Employment License, Certification, Permit VolunteerSTATE OF CALIFORNIA - HEALTH AND HUMAN services AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESREQUEST FOR live scan SERVICE Applicant Submission1.

2 ORI: (Check one) Code assigned by DOJ CCLD A0448 Trustline A1157CA Dept of Social ServicesPO BOX 944243 Sacramento,CA 94244-2430 LIC 9163 (5/05)3. Job Title or Type of License, Certification or Permit:03502( )Name of Applicant :(Please print)_____AKA s:_____CDL :_____ SEX: Male FemaleMisc. No. BIL -HT:_____ WT:_____Misc. No.:_____EYE Color:_____ HAIR Color:_____Home Address: (All applicants must complete)POB:_____SOC:_____LASTLASTFIRST FIRSTMIAGENCY BILLING NUMBER (IF APPLICABLE)ALIEN REGISTRATION, OUT OF STATE DRIVER S LICENSE OR OR PO BOXCITY, STATE AND ZIP CODE6. Facility Number:_____Level of SERVICE DOJ FBI If resubmission (select R2), list Original ATI scan Transaction Completed By:_____ Date_____Transmitting AgencyLSID#ATI Collected/BilledName of OperatorMail Station 19-625. Applicant Information:N/ FOR COMMUNITY CARE LICENSING (CCLD) applicants WHOUSE A live scan SITE (CCLD orDOJ SITE) FOR FINGERPRINTINGI nstructions for the LIC 91631 Originating Response Indicator (ORI): Enter the CCLD or TrustLine ORI code below that pertains to you.

3 Selectone of the following:For CCLD applicants ,check:A0448 For TrustLine applicants , check:A11572 Type of Application: Check the appropriate Title or Type of License, Certification or Permit:Indicate the facility type where you will be applicants using a CCLD live scan Site:Select your CCLD facility type from the left column in the table below. Enter this facility type on this applicants using a Department of Justice (DOJ) live scan Site (Law enforcement office):Select your licensed facility type from the left column, and in the right column find its corresponding DOJabbreviated facility type. Enter the corresponding DOJ abbreviated facility type on this :In the following table you may be able to identify yourself with more than one facility type within eachcategory. Please select only one facility type in any category using the facility that you are most associated with ona day-to-day this is your applicable facility type Enter this abbreviated facility type on your Facility Type by CategoryDOJ Abbreviated CCLD Facility TypeAdult Day Care FacilityAdult Day Support CenterAdult Day/Resident/RehabAdult Residential FacilityChild Care CenterInfant CenterMildly Ill CenterDay Care Cent more/6 ChildSchool Age Child Care CenterFamily Child Care HomeFamily Day CareFoster Family Agency Foster Family / Adoptions AgencyFoster Family / Adopt Family Agency Sub OfficeFoster Family Agency - Certified HomeFoster Family HomeFoster Family HomeGroup Home (6 or less children)Group Home 6 / child lessGroup Home (7 or more)

4 Community Treatment FacilityGroup Home more / 6 childResidential Care Facility for the Chronically IllResidential Care Facilities for the ElderlyResidentl Care Fac ElderlySmall Family HomeTransitional Housing Placement ProgramResid Child Care 6 / lessSocial Rehabilitation FacilityAdult Day / Resident / RehabTrustLine (Voluntary)TrustLine subsidized applicants cannot TrustLine (Subsidized)currently go to non-CCLD live scan sites4 Agency Address Set Contributing Agency:Agency authorized to receive criminal history information:The following information is pre-printed:Agency:CA Dept of Social ServicesMail Code:03502 Street No. BOX 944243, 19-62 Contact Name:N/ACity, State, Zip:Sacramento, CA 94244-2430 Contact Telephone No.:N/A5 Name of Applicant : Enter your full name (last, first, middle initial).AKA s:Other names the Applicant has No:CA Drivers License or CA IDDOB:Date of BirthSEX:Male or FemaleMISC No BIL:Enter the agency billingnumber, if :Height WT:WeightMISC No.

5 :Enter any other associated licensed facility Color: Color of eyesHAIR Color: Color of hairHome Address: Applicant s home : State or Country of BirthSOC:Social Security Number (optional)6 Facility Number:Enter the facility number or assigned OCA number (Agency Identifying Number).Level of SERVICE :Check the DOJ box for a California criminal background check. Check the FBI box for a nationwide backgroundcheck. Note: If a Child Abuse Central Index check (CACI) is required, it will automatically be completed byDOJ and all applicable fees will be charged. There is no entry necessary on the Applicant s resubmission, list Original Applicant Tracking Information (ATI) No.: If your fingerprints were rejected andthis is a resubmission of your prints, enter the original ATI number provided on the reject notice to avoid paying anadditional processing : Enter the facility name and address (you may place a pre-printed mailing label in this area).

6 NOTE: This section not applicable to TrustLine Name:Enter the facility No.:Enter the facility Code:Enter the facility mail code (if applicable).City, State, Zip:Enter the facility city, state and Telephone No.:Enter the facility phone scan Transaction Completed By: This section will be completed by the live scan this form with you the day you are fingerprinted. The live scan Operator will complete section 8. Ifthe live scan Operator is Sylvan/Identix, they will return the completed form to you. Retain this form foryour you use a live scan Operator other than Sylvan/Identix, you will need to take 2 copies of this form. Onecopy will be retained by the Operator and the other you may retain for your records.(ALIEN REGISTRATION, OUT OF STATE DRIVER S LICENSE OR )