Tlr 9163A Form – Fill Out and Use This PDF

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

	REQUEST FOR LIVE SCAN SERVICE			ORIGINAL-Requesting Agency
	FOR TRUSTLINE REGISTRY APPLICANTS
				COPY-Applicant
	Applicant Submission
	1.	ORI:	A1157
		Applicant Type: ■	TrustLine Registry Employee

■TrustLine Registry Volunteer

2.Working Title: Child Care Provider (Health & Safety Code 1596.603)

3.Agency Address Set Contributing Agency:

Sacramento		CA	95814		(	)	N/A
City		State	Zip Code		Contact Telephone No.
4.	Applicant Information:

Name of Applicant: (Please print) ___________________________________________________________________________________

LASTFIRSTMI

AKA’s __________________________________________________				CDL No. _________________________________________
LAST		FIRST
DOB: _________________________		SEX: ■ Male	■ Female	Misc. No.	_________________________________________BIL-	NA
						AGENCY BILLING NUMBER (IF APPLICABLE)
HT:___________________________ WT: ____________________				Misc. No.: ________________________________________
					ALIEN REGISTRATION, OUT OF STATE DRIVER’S LICENSE OR ID.
POB: __________________________________________________				Home Address: (All applicants must complete)
HAIR: ____________________ EYE: _______________				________________________________________________
						STREET OR PO BOX
SOC No. _______________________________________________				________________________________________________
(See Privacy Statement on next page)						CITY, STATE AND ZIP CODE
5. Your Number:	______________________________________________TLR			Level of Service		■X DOJ	■X FBI
If resubmission, list Original ATI No.____________________________
	(must present proof of rejection)
6.		NOTE: NOT APPLICABLE FOR TRUSTLINE APPLICANTS

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

7. Live Scan Transaction Completed By: _____________________________________________ Date __________________________

NAME OF OPERATOR

________________________________________________________________________________________________________________

Transmitting Agency

LSID#

ATI No.

Amount Collected/Billed

TLR 9163A (3/11)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

TRUSTLINE APPLICANTS

Instructions for Completing the Request for Live Scan Service Form

A.Complete this form and the TrustLine Application Form (TLR 2).

Schedule an appointment to have your fingerprints scanned with either the Community Care Licensing Live Scan vendor at 1-800-315-4507 or at a Department of Justice Live Scan site -- either a Police Department or Sheriff’s Office (refer to http://caag.state.ca.us/fingerprints/index.htm).

1 to 3 are pre-printed.

4.Applicant Information:

Name of Applicant: Print your full name (last, first, middle initial)

AKA’s: Other names that you have ever used

CDL No: CA Driver’s License or CA ID

DOB: Date of Birth

SEX: Male or Female

MISC No.: N/A (Pre-Printed)

HT: Height

WT: Weight

MISC No.: Enter Alien Registration, Out of state driver’s license or ID

POB: State or Country of Birth

Home Address: Applicant’s home address; Street or PO Box; City, State, Zip Code

HAIR: Color of hair

EYE: Color of eyes

SOC No.: Social Security Number (Optional, see Privacy Statement below)

5.The first part of the section is pre-printed. If resubmission, list Original 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.

6.is pre-printed.

B. CALL THE LIVE SCAN SITE TO MAKE AN APPOINTMENT

7.Live Scan Transaction Completed by: The Live Scan Operator will complete this section and keep a copy of the form.

It is important that you bring this form with you the day you are fingerprinted; the Live Scan Operator must complete

7.After you’ve had your fingerprints scanned, take a copy of the Live Scan Submission form along with the TrustLine Application form (TLR 2) and the appropriate fee and send or take it to the agency listed in 10 of the TrustLine Application. You must call 24 hours in advance if you cannot keep the appointment. A no-show fee of $5.00 will be charged for missed appointments.

PRIVACY STATEMENT

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of l977 (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 approved, licensed, work at, or be present at, a licensed facility, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871; Welfare and Institutions Code section 361.4). The licensing or approval agency 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 licensing or approval agency (Civil Code section 1798 et seq.). Under the California Public Records Act, the licensing or approval agency 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.

TLR 9163A (3/11)

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