Form Hcs 100 - Application For Home Care Aide Registration
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1
2State of California – Health and Human Services Agency
California Department of Social Services
APPLICATION FOR HOME CARE AIDE REGISTRATION
Please type or print clearly. For instructions on how to complete this form refer to page two. Please ensure
that you include a check or money order in the amount of $35.00, payable to the California Department
of Social Services, and complete the LiveScan form (LIC 9163) to submit fingerprints. Mail this completed
application, the complete Criminal Record Statement (LIC 508), and a check or money order to: The California
Department of Social Services, Home Care Services Bureau, 744 P Street, MS T8-3-90, Sacramento, CA
95814.
If any of the following apply, then you are not eligible for Home Care Aide registration at this time.
Please note, if you continue with the application process, your application will be withdrawn and your
fee will be forfeited.
•
You had an application for a license, TrustLine registration, foster care certificate of approval,
administrator certification, or home care aide registration denied within the past year;
•
You had a license, TrustLine registration, foster care certificate of approval, administrator certification, or
home care aide registration revoked or rescinded within the past two years;
•
You had a criminal record exemption denied within the past two years; and/or
•
You were excluded from all licensed facilities, certified family homes, resource family homes, and/or
home care organizations and have not successfully petitioned for reinstatement.
1. NAME
Last:
First:
Middle:
2. LIST ALL OTHER NAMES YOU HAVE EVER USED, SUCH AS MAIDEN OR ALIASES (AKAs)
3. RESIDENCE ADDRESS
Street:
Apt:
City:
State:
Zip Code:
County:
4. MAILING ADDRESS (If Different):
Street:
Apt:
City:
State:
Zip Code:
County:
5. E-MAIL (Voluntary)
6. DATE OF BIRTH
7. SEX
8. SOCIAL SECURITY NUMBER
9. DRIVER’S LICENSE/IDENTIFICATION CARD/ALIEN
(Voluntary)
REGISTRATION
10. TELEPHONE NUMBERS
Day:
Evening:
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT
TO THE BEST OF MY KNOWLEDGE.
Signature
Date
Federal law (at Title 5 United States Code Section 552a Note) states that: Any federal, state, or local
government agency which requests an individual to disclose his social security account number
shall inform that individual whether that disclosure is mandatory or voluntary, by what statutory or
other authority such number is solicited, and what uses will be made of it.
HCS 100 (1/18)
Page 1 of 2
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