California Form Tlr 3 PDF Details

In the bustling state of California, where the safety and welfare of individuals receiving care is of paramount importance, the TrustLine Registry serves as a cornerstone for ensuring that caregivers meet stringent background check requirements. The California Department of Social Services, through its Community Care Licensing Division, facilitates this process with the TLR 3 form— a critical document designed to streamline the transfer of criminal background clearance information. By providing a mechanism for individuals registered with TrustLine to easily transfer their clearance status to a new or different licensed facility, this form plays a pivotal role in maintaining the integrity and safety standards required within the state. Requiring details such as the registrant's personal information, identification card copy, and association type with the facility, alongside declarations under penalty of perjury regarding the truthfulness of the submitted information, emphasizes the seriousness with which the state approaches this matter. Verifiable through the Caregiver Background Check Bureau (CBCB), the form ensures that only those with cleared backgrounds can seamlessly transition, thereby fortifying the safeguarding measures for vulnerable populations across California.

QuestionAnswer
Form NameCalifornia Form Tlr 3
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesLEGIBLY, TRANSFEREE, SSN, CBCB

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

TRUSTLINE TO COMMUNITY CARE LICENSING

CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST

ATTN: CAREGIVER BACKGROUND CHECK BUREAU (CBCB)

A COPY OF ONE OF THE FOLLOWING IDENTIFICATION CARDS MUST BE SUBMITTED WITH THIS TRANSFER REQUEST:

•California Driver’s License

•California I.D. Card

•Alien Registration Card

•A numbered picture I.D. issued from a state other than California

PLEASE TYPE OR PRINT LEGIBLY

DATE:

PLEASE ASSOCIATE THE FOLLOWING TRUSTLINE REGISTRANT:

LAST NAME

FIRST NAME

MIDDLE INITIAL

STREET ADDRESS:

CITY

STATE

ZIP CODE:

CA DRIVER’S LICENSE #:

DOB:

TRUSTLINE REGISTRANT ID#:

SSN: (OPTIONAL)

TO THE FOLLOWING LICENSED FACILITY:

NAME OF FACILITY:

FACILITY NUMBER:

STREET ADDRESS:

CITY

STATE

ZIP CODE:

TRANSFEREE ASSOCIATION TYPE

■

■

Facility Administrator

Licensee/Applicant

■

■

Corporation Board Member

Non-client Adult Resident

■

■

Employee

Partnership Member

■

■

Certified Home

Spouse of Licensee

I declare under penalty of perjury that the information provided on this application is true and correct. I understand that any false statements may result in the denial or revocation of my license and/or TrustLine Registration.

SIGNATURE

TITLE (APPLICANT, LICENSEE, ADMINISTRATOR, DIRECTOR)

FOR LICENSING USE ONLY

CII Cleared? ■ YES ■ NO

FBI Cleared? ■ YES ■ NO

CACI Cleared? ■ YES ■ NO

CBCB OR COUNTY EMPLOYEE SIGNATURE

DATE

COUNTY LICENSING OFFICES CAN VERIFY THE STATUS OF TRUSTLINE REGISTRANTS BY CALLING

(916) 653-1923

TLR 3 (2/11)

PAGE 1 OF 1

How to Edit California Form Tlr 3 Online for Free

TRUSTLINE can be completed easily. Simply try FormsPal PDF editing tool to get it done without delay. Our tool is continually evolving to present the very best user experience attainable, and that's due to our commitment to constant enhancement and listening closely to user opinions. Starting is simple! Everything you need to do is adhere to the next basic steps below:

Step 1: First, access the tool by clicking the "Get Form Button" at the top of this site.

Step 2: After you open the online editor, you'll see the document prepared to be completed. Apart from filling in different blank fields, you could also perform some other actions with the Document, specifically writing custom textual content, changing the initial text, inserting graphics, affixing your signature to the document, and much more.

This PDF form needs specific details; to guarantee accuracy and reliability, please be sure to heed the following steps:

1. To start off, when filling in the TRUSTLINE, begin with the part that has the following blanks:

Step number 1 for submitting CII

2. Once the previous segment is done, you're ready to add the essential specifics in Facility Administrator, Corporation Board Member, Employee, Certified Home, LicenseeApplicant, Nonclient Adult Resident, Partnership Member, Spouse of Licensee, I declare under penalty of perjury, SIGNATURE, TITLE APPLICANT LICENSEE, CII Cleared YES NO FBI Cleared , CBCB OR COUNTY EMPLOYEE SIGNATURE, DATE, and FOR LICENSING USE ONLY so you're able to move on further.

Filling out section 2 of CII

It's simple to make an error when filling in the Certified Home, for that reason make sure you look again prior to when you submit it.

Step 3: Before finishing this file, ensure that all blank fields are filled in correctly. The moment you determine that it is fine, click “Done." Right after setting up a7-day free trial account at FormsPal, you will be able to download TRUSTLINE or send it via email directly. The document will also be easily accessible in your personal account with your every single change. When using FormsPal, it is simple to complete documents without stressing about personal information incidents or records being distributed. Our secure system ensures that your private details are stored safe.

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