Form Tlr 9163a - Request For Live Scan Service For Trustline Registry Applicants - 2015 Page 2
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2STATE 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/TLR 4).
Schedule an appointment to have your fingerprints scanned at a Department of Justice Live Scan site (refer to
).
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/TLR 4) and the appropriate fee and send or take it to the agency listed in 10 of the TrustLine
Application.
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 (10/15)
PAGE 2 OF 2
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