Administrator Certification Section Forms

Forms are listed first by those used for administrator certification and then by those used by vendors.

NOTE (as of 4/16): ACS will be updating its forms to include reference to the new facility category (STRTP) starting up in July 2016 but if you apply for an STRTP certificate or vendorship before the updated forms are available here, please simply write in “STRTP” where applicable on the form(s).

Administrator Forms:

LIC 9214 Application for Administrator Certification - Both initial and renewal applicants submit this form. In addition, this form is submitted by a previously certified administrator who did not renew their certificate within four (4) years from the date of expiration and so must reapply. NOTE: ACS is not responsible for reviewing the “high school diploma or equivalent …” so initial applicants DO NOT need to submit it with their LIC 9214.

LIC 508 - Criminal Record Statement - The applicant submits this as part of the initial administrator application process.

LIC 9163 - Request for Live Scan Service -This form is used by the applicant to submit their fingerprints to the Department of Justice for processing. The applicant submits a copy to ACS with the initial administrator application.

Vendor Forms:

NEW - AUTOMATION OF VENDOR SERVICES HAS ARRIVED!

The Administrator Certification Section (ACS) now offers a quick and convenient way to submit Vendor Applications and related forms electronically! In using this service, Vendors will be able to submit and track documents and receive ACS notices confirming receipt of Vendor documents.


Registering to access the system is free and easy. A one-time registration for your vendorship will be required upon your first use of service. Registering for an account does not mean you are an approved vendor.


Click the following link to register and sign-in to the platform:

Vendor Automation Platform

For step by step instructions in using the service, see the following link for the
Vendor Automation Manual


Use the following document to submit identifying vendor information with your payment:
Notice of Payment Information


Note - application processing fees must continue to be mailed with identifying vendor information to the ACS at:


CDSS - Community Care Licensing Division
Administrator Certification Section
744 P Street, MS 9-14-47
Sacramento, CA 95814


If you have questions or wish to share feedback on the service, contact Michael Estioko at:
michael.estioko@dss.ca.gov



LIC 9141 - Vendor Application/Renewal - An individual, for profit or nonprofit business or governmental entity submits this form to request ACS approval to become a vendor and offer initial or continuing education courses for facility administrators.

LIC 9140 Request for Course Approval - Vendors submit this request for ACS review and approval of a new or updated course.

LIC 9140A - Request to Add or Replace Instructor - Vendors use this form to request ACS approval to add or replace an instructor of an approved course.

LIC 9139Renewal of Continuing Education Course Approval -Vendors submit this form for ACS approval to renew previously approved courses and to continue to offer these unmodified courses.

LIC 9142A- Roster of Participants - for Vendor Use Only - Vendors use this form (or another format containing at least the same information) to report to ACS names of course participants.

Contact Us

Community Care Licensing Division
Administrator Certification Section
744 P Street, MS 9-14-47 
Sacramento, CA 95814  
916-653-9300
Admincertinfo@DSS.ca.gov

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