Form Lic 9163 - Request For Live Scan Service - Community Care Licensing
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING
Applicant Submission
A0448
1. ORI:
2. Working Title: (Check one)
I
I
I
I
I
Adult Resident other than Client
Employee
License, Certification, Applicant
Volunteer
Home Care Aide
3. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type.”
Day Care Center more/6 Child
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 94244
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
I
I
140406
DOB:_________________________ SEX:
Male
Female
Misc. No.
BIL -
AGENCY BILLING NUMBER (IF APPLICABLE)
HT:__________________________ WT:____________________
Misc. No.:______________________________________
PERMANENT RESIDENT (i-551), 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:_________________________________________________
CITY, STATE AND ZIP CODE
(See Privacy Statement on Page 4)
I
I
6. Facility/Organization 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)
Del Mar Union School District
Employer Name
03333
11232 El Camino Real
Street No.
Street or PO Box
Mail Code (five digit code assigned by DOJ)
San Diego, CA 92130
858-755-9301
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 (12/15)
PAGE 1 OF 4
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Parent category: Medical