Form Tlr 4 - Trustline Registry Ancillary Day Care Center Provider Application Page 3
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4STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
TRUSTLINE REGISTRY
ANCILLARY DAY CARE CENTER PROVIDER APPLICATION
See next page for complete instructions. Use a ball point pen and print clearly.
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 CODE
COUNTY
4.
MAILING ADDRESS (IF DIFFERENT):
P.O. BOX/STREET
APT#
CITY
STATE
ZIP CODE
COUNTY
5.
DATE OF BIRTH
SEX
HEIGHT
WEIGHT
EYE COLOR
HAIR COLOR
6a.
6b.
SOCIAL SECURITY NUMBER (Voluntary)
DRIVER’S LICENSE OR ID# / ALIEN REGISTRATION/OUT-OF-STATE ID#
7.
TELEPHONE NUMBERS:
DAY:
EVENING:
8.
TRANSFER PROCESS: Are you currently licensed or working in, a facility licensed by the California
I
I
Department of Social Services Community Care Licensing?
Yes
No
I
I
Do you want to transfer your background clearance from Community Care Licensing to TrustLine?
Yes
No
(If yes, fingerprints are not required.) Enter the Facility number. Facility #_______________________(Include photocopy of I.D.)
9.
__________________________________________________________
____________________________________
SIGNATURE (REQUIRED)
DATE (REQUIRED)
Mail this Application and the TLR 508 to:
. Department of Social Services
Fees are required to process this application.
10
11.
Caregiver Background Check Bureau
The required fees are listed in the “How To
Attn: TrustLine Registry Program
Apply” section of the application.
P.O. Box 944243, M.S. 9-15-57
Sacramento, CA 94244-2430
12.
The completed TrustLine Registry Criminal Record Statement (TLR 508) must be included with your application.
OFFICIAL USE ONLY
ANCILLARY DAY CARE CENTER
13.
.
14
ID # ____________
CHILD CARE RESOURCE
AND
Name & Address:
REFERRAL PROGRAM
ID#____________
Phone: (
)
OFFICIAL USE ONLY -- LIVE SCAN
. ORI:
A1157
DOJ Billing Code:
15
I
X
Applicant Type:
TrustLine Registry Employee
Working Title:
Ancillary Day Care Center (Health & Safety Code 1596.60)
16
. Agency Address Set Contributing Agency:
CA Dept of Social Services
03502
Agency authorized to receive history information
Mail Code (five-digit code assigned by DOJ)
P.O. Box 944243
Mail Station 9-15-57
N/A
Street No.
Street or P O Box
Contact Name (Mandatory for all school submissions)
Sacramento
CA
94244-2430
(
)
N/A
City
State
Zip Code
Contact Telephone No.
17. Live Scan Transaction Completed by
Name of Operator
Date
:
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
TLR 4 (2/16)
Page 3 of 4
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