Trustline Registry In-Home/license Exempt Child Care Provider Application Page 4
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4STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
TRUSTLINE REGISTRY APPLICATION INSTRUCTIONS
PRINT ALL INFORMATION EXCEPT SIGNATURE
1.
Print your full legal name. Do not use nicknames. The printed name and the signature on the application and the fingerprint card
must
be
the
same.
NOTE:
We
recommend
that
you
use
the
name
that
is
on
your
identification card. If your I.D. lists your maiden name but you are using a married name, use the married name as the main
name and the maiden name as the AKA. If your signature is missing on the application or fingerprint card, the application will be
returned.
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. If
you are using a fingerprint card to submit your prints, make sure your full residence address is listed.
4.
Print your complete mailing address, if different than residence address. Once you are registered, failure to notify the
TrustLine Registry Program of a change of mailing address within 10 days will result in your name being removed from
the Registry.
5.
List your date of birth, sex, (“M” for male or “F” for female), height, weight, eye color, and hair color.
NOTE: You must be 18 years of age or older to apply for the TrustLine Registry.
6.
a)
Print your Social Security Number, 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. 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, 1596.603). The
Department will create a file concerning your criminal background check that will contain certain documents, including infor-
mation that you provide. You have the 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, 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 tele-
vision reporters.
b)
Print your identification number, which is required. NOTE: You must list one of these four I.D.s: California Driver’s
License; California I.D. card; Alien Registration Card; or a numbered, picture I.D. issued from a state other than California.
If the application has only a Social Security Number without one of the four acceptable I.D.s., it will be returned.
7.
List a daytime and evening telephone number.
8.
TRANSFER PROCESS: Mark the appropriate boxes Yes or No. If yes, fingerprints are not required.
9.
You must sign and date the application. If your signature and date are missing, the application will be returned as incomplete.
10. Mail your application and the TrustLine Registry Criminal Record Statement (TLR 508) to the address shown in box 10
Applicant, have you . . .
1. Used exactly the same name on page 3 of the application form and page 1 of the Trustline Registry
Criminal Record Statement (TLR 508) and fingerprint card if a fingerprint card is used?
2. Included the appropriate identification number (i.e. California Driver’s License)?
3. Had your prints taken on an FD-258 fingerprint card or submitted your prints through Live Scan?
4. Signed and dated the application?
5. Included the appropriate fee?
6. Completed, signed and dated the TrustLine Registry Criminal Record Statement (TLR 508)?
11. Read “How To Apply” section.
12. APPLICANT - You must answer the questions on the TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508),
Page 1. If you answered NO to both questions, you must: print your name; provide your address, city, zip code; social security
number (voluntary); California Driver’s License Number, or California ID number, or alien registration
number, or a numbered, picture ID issued from a state other than California. You must sign and date Page 1.
NOTE: IF YOU ANSWERED YES TO BOTH QUESTIONS, YOU MUST COMPLETE THE INFORMATION ASKED ON PAGE
2. YOU MUST ALSO SIGN AND DATE PAGE 2.
AFTER YOU COMPLETE THE TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508), YOU MUST RETURN
IT TO THE AGENCY ADDRESS LISTED IN BOX 10. IF YOU DO NOT RETURN THIS FORM, YOUR APPLICATION WILL BE
CONSIDERED INCOMPLETE. YOUR NAME WILL NOT BE PLACED ON THE TRUSTLINE REGISTRY UNTIL YOU SUBMIT
THE TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508).
13. Please check the appropriate box. Nanny Agencies and Transport Escort Services must print their name and address. Write
your agency code number in this box.
14. Official Use -- Child Care Resource and Referral Program: ID #
15. Official Use -- Live Scan
16. Official Use -- Agency Address
17. Official Use -- Live Scan Operator
TLR 2 (2/09)
Page 4 of 4
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