Form LIC 9163 at a glance
What it is: LIC 9163 is the Request for Live Scan Service - Community Care Licensing Applicant Submission.
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.
What to bring and attach to Form LIC 9163
Take two copies of this form with you the day you are fingerprinted. One copy will be retained by the Operator and the other you may retain for your records.
A filled-in Form LIC 9163 example: a new family child care licensee requests Live Scan
How to fill out Form LIC 9163, box by box
Working Title
Working Title (Check one): Adult Resident other than Client, Employee, License, Certification, Applicant, Volunteer, Home Care Aide Registry Applicant.
Authorized Applicant Type
Indicate the facility type where you will be working. Enter the corresponding DOJ abbreviated facility type.
Please select only one facility type in any category using the facility that you are most associated with on a day-to-day basis.
Agency Address Set Contributing Agency
Agency authorized to receive criminal history information: The following information is pre-printed.
Applicant Information
Applicant Information: Print your full name (last, first, middle initial).
AKA's: Other names the applicant has used.
CDL No: CA Drivers License or CA ID.
DOB: Date of Birth. SEX: Male or Female. HT: Height. WT: Weight. EYE Color: Color of eyes. HAIR Color: Color of hair. Home Address: Applicant's home address. POB: State or Country of Birth.
Agency Billing Number, Misc. No. and SOC
Misc No: BIL - Enter the agency billing number, if applicable. MISC No.: Enter any other identification numbers.
SOC: Social Security Number (optional).
The requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and the criminal record check.
Facility Number
Facility Number: Enter the facility number or assigned OCA number (Agency Identifying Number).
Original ATI No.
If resubmission for fingerprint quality, list Original Applicant Tracking Information (ATI) No.: If your fingerprints 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.
Employer
Employer: Enter the facility name and address for which you are being printed.
Employer Name: Enter the facility/organization name. Street No.: Enter the facility/organization address. Mail Code: Enter the facility/organization mail code (if applicable). City, State, Zip: Enter the facility/organization city, state and zip. Agency Telephone No.: Enter the facility/organization phone number.
Live Scan Transaction Completed By
Live Scan Transaction Completed By: This section will be completed by the Live Scan operator.
More rules for Form LIC 9163
Originating Response Indicator (ORI): Preprinted.
Common questions about Form LIC 9163
What is lic 9163?
LIC 9163 is the Request for Live Scan Service - Community Care Licensing Applicant Submission. If you have any questions about this form, please contact your local licensing regional office.
Are there fees?
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.
Sources
[1] Form LIC 9163 (12/15), Request for Live Scan Service - Community Care Licensing Applicant Submission, California Department of Social Services (the Official source link on this page).
