Form Lic 9163 PDF Details

Form Lic 9163 is a critical form for businesses in California. This form is used to collect information about the company, such as its name and authorized agent, as well as other important details. Failing to submit this form may result in penalties from the state. Here's what you need to know about Form Lic 9163 and how to complete it correctly. For more information on Form Lic 9163 and other business requirements in California, visit our website today. We can help you keep your business compliant with all state regulations.

QuestionAnswer
Form NameForm Lic 9163
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameslic9163 form, form lic 9163, lic9163, live scan form lic 9163

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

REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING

Applicant Submission

1.

ORI: A0448

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Working Title: (Check one)

 

 

 

 

 

 

 

 

 

Adult Resident other than Client

Employee

License, Certification, Applicant

Volunteer

 

 

 

 

 

 

3.

Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility Type.”

 

 

 

 

 

 

 

 

 

 

4.

Agency Address Set Contributing Agency:

 

 

 

 

 

 

 

CA Dept of Social Services

 

 

 

 

 

 

03502

 

 

 

 

 

 

 

 

 

 

 

 

Agency authorized to receive criminal history information

 

 

 

 

 

Mail Code (five-digit code assigned by DOJ)

PO BOX 944243

 

Mail Station 9-15-62

 

 

 

N/A

Street No.

Street or PO Box

 

 

 

 

 

Contact Name (Mandatory for all school submissions)

Sacramento,

CA

94244-2430

 

 

 

(

)

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

 

Contact Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

5.

Applicant Information:

 

 

 

 

 

 

 

 

 

Name of Applicant: (Please print)_________________________________________________________________________________

 

LAST

 

 

FIRST

 

 

MI

AKA’s:________________________________________________

 

CDL No._______________________________________

LAST

FIRST

 

 

 

 

 

 

 

 

 

DOB:_________________________

SEX: Male

Female

 

Misc. No. BIL -

 

 

 

 

 

 

 

 

 

 

AGENCY BILLING NUMBER (IF APPLICABLE)

HT:__________________________

WT:____________________

 

Misc. No.:______________________________________

 

 

 

 

 

ALIEN REGISTRATION, OUT OF STATE DRIVER’S LICENSE OR I.D.

EYE Color:____________________

HAIR Color:______________

 

Home Address: (All applicants must complete)

POB:_________________________________________________

 

 

 

 

 

 

 

 

 

 

STREET OR PO BOX

 

 

 

 

 

 

 

 

 

 

 

SOC:_________________________________________________

 

 

 

 

 

 

 

 

(See Privacy Statement on Page 4)

 

 

 

CITY, STATE AND ZIP CODE

6. Facility Number:__________________________________________

 

 

 

Level of Service

DOJ

FBI

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)

Employer Name

 

 

 

 

 

 

 

 

 

 

 

Street No.

Street or PO Box

 

 

 

Mail Code (five digit code assigned by DOJ)

 

 

 

 

 

 

City

State

Zip Code

 

Agency Telephone No. (Optional)

8.

 

 

 

Live Scan Transaction Completed By:______________________________________________

Date__________________________

 

 

Name of Operator

 

 

 

 

 

Transmitting Agency

LSID#

ATI No.

Amount Collected/Billed

LIC 9163 (3/11)

PAGE 1 OF 4

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.

If this is your applicable facility type

Enter this abbreviated facility type on your application.

 

 

 

CCLD Facility Type by Category

 

DOJ Abbreviated CCLD Facility Type

 

 

 

Adult Day Care Facility

 

 

Adult Day Support Center

 

Adult Day/Resident/Rehab

Adult Residential Facility

 

 

Child Care Center

 

 

Infant Center

 

 

Mildly Ill Center

 

Day Care Cent more/6 Child

School Age Child Care Center

 

 

Family Child Care Home

 

Family Day Care

Foster Family Agency

 

 

Foster Family / Adoptions Agency

 

Foster Family / Adopt Emp.

Foster Family Agency Sub Office

 

 

Foster Family Agency - Certified Home

 

 

Foster Family Home

 

Foster Family Home

Group Home (6 or less children)

 

Group Home 6 / child less

Group Home (7 or more)

 

 

Community Treatment Facility

 

Group Home more / 6 child

Residential Care Facility for the Chronically Ill

 

Residential Care Facilities for the Elderly

 

Residentl Care Fac Elderly

Small Family Home

 

 

Transitional Housing Placement Program

 

Resid Child Care 6 / less

Social Rehabilitation Facility

 

Adult Day / Resident / Rehab

LIC 9163 (3/11)

PAGE 2 OF 4

4. Agency Address Set Contributing Agency:

 

 

Agency authorized to receive criminal history information:

 

The following information is pre-printed:

 

 

Agency: CA Dept of Social Services

Mail Code: 03502

 

Street No.: P.O. BOX 944243, M.S. 9-15-62

Contact Name: N/A

 

 

 

 

 

 

City, State, Zip: Sacramento, CA 94244-2430

Contact Telephone No.:

N/A

5.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

MISC No: BIL - Enter the agency billing

 

 

 

number, if applicable

HT: Height

WT: Weight

MISC No.: Enter any other identification numbers

 

 

 

(ALIEN REGISTRATION, OUT OF STATE DRIVER’S LICENSE OR I.D.)

EYE Color: Color of eyes HAIR Color: Color of hair

Home Address: Applicant’s home address

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.

Employer Name:

Enter the facility name.

Street No.:

Enter the facility address.

Mail Code:

Enter the facility mail code (if applicable).

City, State, Zip:

Enter the facility city, state and zip.

Agency Telephone No.:

Enter the facility phone number.

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

Take this form with you the day you are fingerprinted. The Live Scan Operator will complete section 8. If the Live Scan Operator is IBT - L1, they will return the completed form to you. Retain this form for your records.

If you use a Live Scan Operator other than IBT - L1, you will need to take 2 copies of this form. One copy will be retained by the Operator and the other you may retain for your records.

LIC 9163 (3/11)

PAGE 3 OF 4

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, the law requires that you complete a criminal back- ground 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 pro- vide. 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 has a criminal record exemption. The Department must also tell people who ask the name of a licensed facility that has a licensee, em- ployee, resident, or other person with a criminal record exemption.

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

LIC 9163 (3/11)

PAGE 4 OF 4

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This form needs specific information; to ensure consistency, please adhere to the tips further on:

1. The lic 9163 live scan form needs certain information to be typed in. Ensure that the next blank fields are completed:

How one can complete lic 9163 live scan stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - DOB SEX Male Female, Misc No BIL, AGENCY BILLING NUMBER IF APPLICABLE, HT WT, Misc No ALIEN REGISTRATION OUT OF, EYE Color HAIR Color, Home Address All applicants must, POB, SOC, See Privacy Statement on Page, Facility Number, STREET OR PO BOX, CITY STATE AND ZIP CODE, Level of Service DOJ FBI, and If resubmission for fingerprint with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

lic 9163 live scan completion process detailed (part 2)

It's simple to make a mistake while filling in the See Privacy Statement on Page, thus you'll want to look again prior to when you send it in.

3. Completing Street No Street or PO Box, Mail Code five digit code assigned, City State Zip Code, Agency Telephone No Optional, Live Scan Transaction Completed By, Name of Operator, Transmitting Agency, LSID, ATI No, Amount CollectedBilled, LIC, and PAGE OF is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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