Form Tlr 9163a - Request For Live Scan Service For Trustline Registry Applicants - 2015

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA 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:
I
TrustLine Registry Employee
I
TrustLine Registry Volunteer
2.
Working Title:
Child Care Provider (Health & Safety Code 1596.603)
3.
Agency Address Set Contributing Agency:
CA Dept of Social Services
03502
Mail Code (five-digit code assigned by DOJ)
Agency authorized to receive criminal history information
744
“P” Street
N/A
Contact Name (Mandatory for all school submissions)
Street No.
Street or PO Box
(
)
Sacramento
CA
95814
N/A
City
State
Zip Code
Contact Telephone No.
4. Applicant Information:
Name of Applicant: (Please print) ___________________________________________________________________________________
LAST
FIRST
MI
AKA’s __________________________________________________
CDL No. _________________________________________
LAST
FIRST
BIL-
NA
I
I
DOB: _________________________ SEX:
Male
Female
Misc. No. _________________________________________
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
TLR
5. Your Number: ______________________________________________
Level of Service
I
X
DOJ
I
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)
N/A
__________________________________________________________________
Employer Name
N/A
N/A
__________________________________________________________________
_______________________________________________________
Street No
Street or PO Box
Mail Code (five-digit code assigned by DOJ)
N/A
N/A
__________________________________________________________________
_______________________________________________________
City
State
Zip Code
Agency Telephone No. (Optional)
7.
Live Scan Transaction Completed By: _____________________________________________
Date __________________________
NAME OF OPERATOR
________________________________________________________________________________________________________________
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
TLR 9163A (10/15)
PAGE 1 OF 2

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