Form Hcs 100 - Application For Home Care Aide Registration Page 2
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2State of California – Health and Human Services Agency
California Department of Social Services
APPLICATION FOR HOME CARE AIDE REGISTRATION INSTRUCTIONS
To become listed on the Home Care Aide Registry, you must complete and mail the attached application
(HCS 100), the Criminal Record Statement (LIC 508), and a check or money order to the address listed
on the top of the application form. You will also need to complete the LiveScan form (LIC 9163) to submit
fingerprints. If you are applying as an Independent Home Care Aide, please contact the Home Care Services
Bureau at (877) 424-5778 to obtain the Home Care Aide Registry facility number for LiveScan fingerprinting.
1. Print your full legal name and do not use nicknames.
• NOTE: It is recommended you use the name that is on your ID card. If your ID lists your maiden name
but you are using a married name, use the married name as the main name and maiden name as the
AKA.
2. List all other names you have ever used.
• NOTE: This includes aliases such as ‘Beth’ if used as a legal name.
3. Print your complete residence address.
• NOTE: City names must be spelled out. Abbreviated city names will not be accepted.
4. Print your complete mailing address, if different than residence address.
• NOTE: Once you are registered, failure to notify the Home Care Services Bureau of a change of mailing
address within 10 days will result in forfeiture of your registration.
5. Please list your email address.
6. Please list your date of birth in MM/DD/YY format.
• NOTE: You must be 18 years of age or older to apply to be listed on the Home Care Aide Registry.
7. Please list “M” for male or “F” for female.
8. Print your Social Security Number.
• NOTE: Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil
Code Sections 1798 et seq.) notice is given for the request of your Social Security Number (SSN) on this
form. The requested SSN is voluntary; however, failure to provide the SSN may delay the processing
of this form and the criminal record check. The law requires that you complete a background check
(Health and Safety Code Section 1796.24). The Department will create a file concerning your criminal
background check that will contain certain documents, including information that you provide. You have a
right to access certain records containing your personal information maintained by the Department (Civil
Code Section 1798 et seq.). Under the California Public Records Act and the Freedom of Information
Act, the Department 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.
9. Print your ID number, which is required.
• NOTE: You must list one of these four IDs: California Driver’s License; California ID card; Alien
Registration Card; or a numbered, picture ID issued from a state other than California. If the application
only has a Social Security Number without one of these four acceptable IDs, it will be returned.
10. List a daytime and evening telephone number.
Signature Block
You must sign and date the application. If your signature or the date is missing, the application will be returned
as incomplete.
Have you remembered the following?
Used exactly the same name on the application form (HCS 100) and page one (1) of
the Criminal Record Statement (LIC 508)?
Included the appropriate ID number (i.e. California Driver’s License)?
Submitted your fingerprints through Live Scan?
Signed and dated the application?
Included a check or money order as payment of fees?
Completed, signed, and dated the Criminal Record Statement (LIC 508)?
HCS 100 (1/18)
Page 2 of 2
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