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This version of the form is not currently in use and is provided for reference only. Download this version of
Form LIC9163
for the current year.
Form LIC9163 Request for Live Scan Service - Community Care Licensing - California
What Is LIC 9163 Form?
Form LIC 9163, Live Scan Service is a legal document which must be completed if you wish to work at, be licensed, or present at a licensed community care facility or organization. "Live Scan Fingerprinting" (or "Live Scan" for short) will electronically transfer your personal details and images of your fingerprints to the Department of Justice (DOJ).
Alternate Name:
- Live Scan Form.
This form was released by the California Department of Social Services (CDSS) , a component of the California Health and Human Services Agency (CHHS) . The latest version of the form was issued on December 1, 2015 , with all previous editions obsolete. You can download a fillable LIC 9163 Form through the link below.
Form LIC 9163 (SP), Petición para Que Se Tomen Las Huellas Digitales Electrónicamente (Live Scan) (a Spanish version of Form LIC 9163) can be downloaded using this link. Form LIC 9163B, Request For Live Scan Service - Long Term Care Ombudsman, is a related document filled out by individuals who will work as a long-term care ombudsman under the state program intended to resolve complaints made by residents in various long-term care facilities.
How to Fill Out LIC 9163 Form?
Follow these steps to complete the Live Scan Form:
- Check the appropriate working title. You are free to choose between an adult resident other than the client, employee, license/certification applicant, volunteer, or home care aide registry applicant.
- Indicate the type of facility where you will be working. The second page of the form contains a table with a list of licensed facility types and their DOJ abbreviated names - select the facility that you are most associated with on a daily basis.
- Write down the applicant's information. State your full name, other names you have used, driver's license number or ID number, date of birth, sex, height, weight, color of eyes and hair, home address, and place of birth. You may enter your social security number if you wish. If applicable, provide any other identification numbers and the agency billing number.
- Enter the number of the facility or organization. If you are resubmitting your prints, provide the original Applicant Tracking Information (ATI) number written on the reject notice.
- State the details of the facility in which you will work - the name, address, and telephone number of the employer.
Note that the LIC 9163 Form contains pre-printed information: Originating Response Indicator (ORI), name and address of the agency authorized to receive criminal history information, and level of service, so there is no need to enter these details elsewhere. The last section of the form is completed by a Live Scan operator.
Find the closest Live Scan location, schedule an appointment, and take two copies of the Live Scan Form with you the day you are fingerprinted. One copy is for the Live Scan operator and the other you may keep for your records.
What Is an LSID Number on LIC 9163 Form?
An LSID number, or Life Science Identifier, is used to name and locate data online. This number is written on the LIC 9163 Form by the Live Scan operator to identify the transmitting agency along with the agency's name and the ATI number. This information is submitted directly to the DOJ which conducts a criminal background check, based on the applicant's fingerprints.
Download Form LIC9163 Request for Live Scan Service - Community Care Licensing - California
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