Application For Home Care Aide Registration
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1
2COMMUNITY CARE LICENSING DIVISION HOME
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CARE SERVICES BUREAU
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR HOME CARE AIDE REGISTRATION
For Department Use Only
Please type or print clearly. For instructions on how to complete this form refer to page two. Please
LIC 508 FILED WITH APPLICATION?
ensure that you include a check or money order in the amount of $25.00 payable to the California
Department of Social Services and complete LiveScan form (LIC 9163) and submit fingerprints.
I
I
YES
NO
Mail this completed application, the complete Criminal Record Statement (LIC 508) and a check
FEES INCLUDED?
AMOUNT
or money order to: The California Department of Social Services, Home Care Services Bureau
I
I
YES
NO
744 P Street, MS T8-3-90, Sacramento, CA 95814.
I
I
New Application
Renewal Application
1. NAME
LAST:
FIRST:
MIDDLE:
2. LIST ALL OTHER NAMES YOU HAVE EVER USED, SUCH AS MAIDEN OR ALIASES (AKAs)
3. RESIDENCE ADDRESS
STREET:
APT:
CITY:
STATE:
ZIP:
COUNTY:
4. MAILING ADDRESS (If Different):
P.O. BOX/STREET:
APT:
CITY:
STATE:
ZIP:
COUNTY:
5. E-MAIL (Voluntary)
6. DATE OF BIRTH
7. SEX
8. SOCIAL SECURITY NUMBER (Voluntary)
9. DRIVERS LICENSE NUMBER/IDENTIFICATION CARD NUMBER
10. TELEPHONE NUMBERS
DAY:
EVENING:
TRANSFER PROCESS
I
I
11
. Are you currently registered on TrustLine Registry Program, or licensed by or
YES
NO
If YES, please list below.
working in a facility that is licensed by the California Department of Social Services,
Community Care Licensing Division?
11a. Please provide the Personnel ID (Per ID) number _______________________________________________________________________
I
I
12.
Do you want to transfer your background clearance from TrustLine Registry
YES
NO
If YES, please list below.
Program or Community Care Licensing facility to the Home Care Aide Registry?
Please note: If you elect to transfer, fingerprints are not required; however, you must provide a photocopy of your ID with this application.
12a. Please enter the TrustLine Registry number or facility number transferring from:
HOME CARE ORGANIZATION AFFILIATION
I
I
13.
Are you currently affiliated to or applying to become affiliated with a Home Care Organization?
YES
NO
If YES, please list below.
Home Care Organization Number
Home Care Organization Name
Home Care Organization on the LiveScan form:
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
DATE
SIGNATURE
Federal law (at Title 5 United States Code Section 552a Note) states that: Any federal, state, or local government agency which requests an individual to disclose
his social security account number shall inform that individual whether that disclosure is mandatory or voluntary, by what statutory or other authority such
number is solicited, and what uses will be made of it.
HCS 100 (12/15)
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