Form Tlr 3 - Trustline To Community Care Licensing Criminal Background Clearance Transfer Request

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
TRUSTLINE TO COMMUNITY CARE LICENSING
CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST
ATTN: CAREGIVER BACKGROUND CHECK BUREAU (CBCB)
A COPY OF ONE OF THE FOLLOWING IDENTIFICATION CARDS MUST BE SUBMITTED WITH THIS TRANSFER
REQUEST:
•
California Driver’s License
•
California I.D. Card
•
Alien Registration Card
•
A numbered picture I.D. issued from a state other than California
DATE:
PLEASE TYPE OR PRINT LEGIBLY
PLEASE ASSOCIATE THE FOLLOWING TRUSTLINE REGISTRANT:
LAST NAME
FIRST NAME
MIDDLE INITIAL
STREET ADDRESS:
CITY
STATE
ZIP CODE:
CA DRIVER’S LICENSE #:
DOB:
TRUSTLINE REGISTRANT ID#:
SSN: (OPTIONAL)
TO THE FOLLOWING LICENSED FACILITY:
NAME OF FACILITY:
FACILITY NUMBER:
STREET ADDRESS:
CITY
STATE
ZIP CODE:
TRANSFEREE ASSOCIATION TYPE
■ ■
■ ■
■ ■
■ ■
Facility Administrator
Corporation Board Member
Employee
Certified Home
■ ■
■ ■
■ ■
■ ■
Licensee/Applicant
Non-client Adult Resident
Partnership Member
Spouse of Licensee
I declare under penalty of perjury that the information provided on this application is true and correct. I understand that any
false statements may result in the denial or revocation of my license and/or TrustLine Registration.
SIGNATURE
TITLE (APPLICANT, LICENSEE, ADMINISTRATOR, DIRECTOR)
FOR LICENSING USE ONLY
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
CII Cleared?
YES
NO
FBI Cleared?
YES
NO
CACI Cleared?
YES
NO
CBCB OR COUNTY EMPLOYEE SIGNATURE
DATE
COUNTY LICENSING OFFICES CAN VERIFY THE STATUS OF TRUSTLINE REGISTRANTS BY CALLING
(916) 653-1923
TLR 3 (2/11)
PAGE 1 OF 1

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