Form Lic 9163 Facility Number – Fill Out and Use

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICES

REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING

Applicant Submission

Name of Applicant: (Please print)_________________________________________________________________________________

If resubmission for fingerprint quality (select R2), list Original ATI No.________________________

7. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)

GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO

USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING

Instructions for the LIC 9163

1.Originating Response Indicator (ORI): Preprinted

2.Working Title: Check the appropriate box

3.Authorized Applicant Type: Indicate the facility type where you will be working.

Select your licensed facility type from the left column, and in the right column find its corresponding DOJ abbreviated facility type. Enter the corresponding DOJ abbreviated facility type on this line.

Note: In the following table you may be able to identify yourself with more than one facility type within each category. Please select only one facility type in any category using the facility that you are most associated with on a day-to-day basis.

5.Applicant Information: Print your full name (last, first, middle initial).

POB: State or Country of Birth

SOC: Social Security Number (optional) (See Privacy Statement on Page 4)

6.Facility Number: Enter the facility number or assigned OCA number (Agency Identifying Number).

Level of Service: Preprinted

Note: If a Child Abuse Central Index (CACI) check is required, it will automatically be completed by DOJ and all applicable fees will be charged. There is no entry necessary on the applicant’s part.

If resubmission for fingerprint quality, list Original Applicant Tracking Information (ATI) No.: If your finger- prints were rejected and this is a resubmission of your prints, enter the original ATI number provided on the reject notice to avoid paying an additional processing fee.

7.Employer: Enter the facility name and address for which you are being printed.

8.Live Scan Transaction Completed By: This section will be completed by the Live Scan operator.

Take two copies of this form with you the day you are fingerprinted. The Live Scan Operator will complete section 8. One copy will be retained by the Operator and the other you may retain for your records.

PRIVACYSTATEMENT

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of Justice uses a person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and the criminal record check.

In order to be licensed, work at, or be present at, a licensed facility/organization, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871). The Department will create a file concerning your criminal background check that will contain certain documents, including information that you provide. You have the right to access certain records containing your personal information maintained by the Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have to provide copies of some of the records in the file to members of the public who ask for them, including newspaper and television reporters.

NOTE: IMPORTANT INFORMATION

The Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has a criminal record exemption. The Department must also tell people who ask the name of a licensed facility/organization that has a licensee, employee, resident, or other person with a criminal record exemption.

If you have any questions about this form, please contact your local licensing regional office.