Fillable TRUSTLINE TO COMMUNITY CARE LICENSING CRIMINAL BACKGROUND CLEARANCE (California)

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TRUSTLINE TO COMMUNITY CARE LICENSING CRIMINAL BACKGROUND CLEARANCE (California)

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File type: PDF

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FBI Cleared?
■ ■ ■ ■
■ ■ ■ ■
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
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#:
TO THE FOLLOWING LICENSED FACILITY:
NAME OF FACILITY:
STREET ADDRESS:
CITY
■ Facility Administrator
■ Licensee/Applicant
TRANSFEREE ASSOCIATION TYPE
■
Corporation Board Member
■ Employee
DATE:
SSN: (OPTIONAL)
FACILITY NUMBER:
STATE
ZIP CODE:
■ Certified Home
■
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 ■■ 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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TRUSTLINE TO COMMUNITY CARE LICENSING CRIMINAL BACKGROUND CLEARANCE (California)

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Completed 1 June 2021

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