Form Lic 198 PDF Details

Form Lic 198 is a document that is used to record the particulars of a form, such as its name, revision number, author, purpose, and other relevant information. The form can then be referenced by this information when it is used or filed. This document helps to keep track of forms and their revisions, so that users know which version they are working with. It also allows for easy identification of the form's creator and purpose. When completing Form Lic 198, be sure to include all the pertinent details about your form. Doing so will help ensure that your form can be easily located and utilized in the future.

QuestionAnswer
Form NameForm Lic 198
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessubmitting, recheck, lic 198, exemption

Form Preview Example

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

CHILD ABUSE CENTRAL INDEX CHECK FOR COUNTY LICENSED FACILITIES

FOR COUNTY LICENSING OFFICE USE ONLY

COUNTY LICENSING OFFICE ADDRESS STAMP

NOTE: APPLICANT/LICENSEE MUST NOT SEND THIS FORM DIRECTLY TO DEPARTMENT OF JUSTICE

(This form is to be processed through your county licensing office)

Complete ALL items checked (✔)

Include $15.00 for each Child Abuse Central Index Check. (There is no exemption from this fee) Make check or money order payable to the Department of Justice.

We are required by law to check the names of all persons who apply for a license or seek employment in a child day care or residential facility caring for children against the Child Abuse Central Index. Persons required to submit fingerprints for a child care facility (day or residential) must also fill out this form. Please complete the information below. The Licensee is responsible for submitting fingerprints and this form along with the Child Abuse Central Index Check processing fee to the county licensing office.

TYPE OR PRINT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

✔

DATE SENT________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

 

LAST

 

 

 

 

 

 

 

 

 

FIRST

MIDDLE

✔

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all other names you have ever used such as maiden name or aliases:

 

 

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

 

✔

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

✔

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT ADDRESS

 

 

STREET

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP CODE

✔

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

✔

 

 

 

HEIGHT ✔

 

 

 

 

 

WEIGHT ✔

 

 

 

 

HAIR COLOR ✔

EYE COLOR ✔

DRIVER'S LICENSE NUMBER ✔

■ MALE

■ FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH ✔

 

SOCIAL SECURITY NUMBER ✔

 

 

 

MO. DAY

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

✔ FACILITY NUMBER:

________________________________________________________________________________________

✔ FACILITY NAME:

________________________________________________________________________________________

✔ FACILITY ADDRESS:

________________________________________________________________________________________

 

STREET

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

FOR LICENSING OFFICE USE ONLY

 

 

 

 

DO NOT FILL IN BELOW

 

 

Date Sent __________________

Date Re-sent _________________

 

 

■This is a recheck. See attached Criminal Record Report

FOR DEPARTMENT OF JUSTICE USE ONLY

The result of a name search in the Child Abuse Central Index is as follows:

■The subject of the attached report MAY be the same as the subject of your inquiry.

■

■

No record on the above listed person.

Too many possible matches to identify. See attached listing.

LIC 198 (2/01)

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