Get Lic 9163

Filling out the Lic 9163 form is an essential step for individuals seeking to undergo a background check for work in long-term care settings in California. This guide provides a comprehensive overview of each section of the form along with clear instructions to ensure a smooth submission process.

Follow the steps to complete the Lic 9163 form online.

1. Click the ‘Get Form’ button to obtain the Lic 9163 and open it in your preferred digital editor.
2. In Section 1, provide the Originating Response Indicator (ORI), which is preprinted on the form as A0448.
3. For Section 2, enter the Working Title, which is also preprinted as Ombudsman.
4. In Section 3, confirm the Authorized Applicant Type by ensuring it indicates Ombudsman.
5. Complete Section 4 by entering the Agency Address Set Contributing Agency, which should read CA Dept of Social Services, along with the assigned Mail Code of 03502, and the full mailing address including PO Box and contact details.
6. Move to Section 5, where you will provide the Applicant Information. This includes your full name (last, first, middle initial), any known aliases, California Driver's License number, date of birth, sex, height, weight, and additional identification numbers, if applicable.
7. Fill in your Eye Color and Hair Color in the designated fields within Section 5.
8. Ensure you have entered your Home Address in Section 5, including the appropriate city, state, and ZIP code.
9. If applicable, enter any details for Facility Number and Level of Service as indicated in Section 6.
10. If this is a resubmission of prints, enter the original Applicant Tracking Information (ATI) number in Section 7.
11. In the Employer section, fill in the details for your employer, which is the LTC Ombudsman Program, alongside the full address for confirmation.
12. Lastly, leave Section 8 blank; this will be completed by the Live Scan operator after your fingerprinting.
13. After filling out the form, review the information for accuracy. You can then save changes, download, print, or share the submitted form as needed.

Complete your Lic 9163 form online to ensure a timely processing of your background check.