Form Tlr 1 - Trustline Registry In-Home/license Exempt Child Care Provider Program California Department Of Social Services Background Check Application Page 3
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4TRUSTLINE REGISTRY
IN-HOME/LICENSE EXEMPT CHILD CARE PROVIDER PROGRAM
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
BACKGROUND CHECK APPLICATION
(See the next page for further 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 LIC OR ID# / ALIEN REG/OUT-OF-STATE ID# (Required)
7.
TELEPHONE NUMBERS: (Include Area Code)
DAY:
EVENING:
8.
TRANSFER PROCESS: Are you currently licensed or working in a facility licensed by the California Department of Social Services
Community Care Licensing or have you worked in a licensed facility within the last three years?
YES
NO
I
I
If Yes, do you want to transfer your Criminal History clearance from Community Care Licensing to TrustLine?
I
YES
I
NO
(If Yes, fingerprints are not required.) Enter the Facility number. Facility # or Personnel Identification # __________________
(Include photocopy of I.D.)
9.
___________________________________________________________
_____________________________________
SIGNATURE (REQUIRED)
DATE (REQUIRED)
10. THE COMPLETED TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508) MUST BE INCLUDED WITH
YOUR APPLICATION
11. Return this application and the TLR 508 to
12.
County Welfare Department Stage 1 and Cal Learn ONLY
I II
this address.
2
County:_________________________________________ County ID:
CalWORKs Child Care Program:
Stage 1________
Cal Learn________
Case Number(s):
1)____________________________ 2)_________________________
County Worker Name:____________________________
__________________________
PRINT
SIGNATURE
Worker Phone No:_______________________________
Date:______________________
13.
Child Care Resource and Referral/Alternative Payment Program Use Only
Payment Program: Stage 1__________ Stage 2__________ Stage 3__________ CCDBGAPP__________ GFAPP__________
County:___________________________________________________________________________________________________ID#_____________
Child Care Resource and Referral Program:______________________________________________________________________ID#_____________
Alternative Payment Program (including CWDs w/APP contracts with CDE and Community Colleges):________________________ID#_____________
Case number(s):
1)______________________________
2)_________________________________
County Worker Name: (If Applicable)______________________________________________ Worker Phone #______________________________
14.
OFFICIAL USE ONLY - LIVE SCAN
ORI:
A1157
Applicant Type:
CalWORKs/CDE
Working Title:
Child Care Provider (Health & Safety Code 1596.603)
15.
Agency Address Set Contributing Agency:
CA Dept of Social Services
03502
Billing Code
Agency authorized to receive criminal 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 PO Box
Contact Name (Mandatory for all school submissions)
(
)
N/A
Sacramento
CA
94244-2430
City
State
Zip Code
Contact Telephone No.
16.
Live Scan Transaction Completed by: Name of Operator ________________________________________ Date______________
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
Page 3 of 4
FOR DEPARTMENT OF SOCIAL SERVICES ONLY
TLR 1 (12/15)
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