
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:
TO THE FOLLOWING LICENSED FACILITY:
LAST NAME
CA DRIVER’S LICENSE #:
TRUSTLINE REGISTRANT ID#:
FIRST NAME
DOB:
SSN: (OPTIONAL)
NAME OF FACILITY:
STREET ADDRESS: CITY STATE ZIP CODE:
STREET ADDRESS: CITY STATE ZIP CODE:
FACILITY NUMBER:
MIDDLE INITIAL
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
COUNTY LICENSING OFFICES CAN VERIFY THE STATUS OF TRUSTLINE REGISTRANTS BY CALLING
(916) 653-1923
TLR 3 (2/11) PAGE 1 OF 1
TRANSFEREE ASSOCIATION TYPE
■■ Facility Administrator ■■ Corporation Board Member ■■ Employee ■■ Certified Home
■■ Licensee/Applicant ■■ Non-client Adult Resident ■■ Partnership Member ■■ Spouse of Licensee
CII Cleared? ■■ YES ■■ NO FBI Cleared? ■■ YES ■■ NO CACI Cleared? ■■ YES ■■ NO
CBCB OR COUNTY EMPLOYEE SIGNATURE DATE