Administrator Certification Bureau Forms
Forms are listed first by those used for administrator certification and then by those used by vendors.
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: ACB 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 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 ACB with the initial administrator application.
Vendor Forms:
New! The ACB Now Accepts Online Payments for Vendor Applications and Request for Course Approvals
Processing fees for Vendor/Renewal Applications and Request for Course Approvals can now be paid via credit card on the Vendor Automation Platform. Please note that online payments are not available for applications submitted via postal mail. For additional information, please refer to the section below.
Vendor Information – Application Processing
The ACB encourages vendors to submit vendor applications, course requests, change of instructor requests, rosters, etc., using the Vendor Automation Platform. The platform allows vendors to track submissions and receive ACB notices confirming the transaction.
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.
If you have questions or wish to share feedback on the Vendor Automation Platform, contact the Administrator Certification Bureau – Vendor Support and Review Unit at: ACSVendorInfo@dss.ca.gov
Click the following link to register and sign-in to the platform:
Vendor Automation Platform
Application Processing Fees
Credit card payments for application processing fees are only available for applications submitted online through the Vendor Automation Platform. For any Vendor Applications or Request for Course Approvals submitted via postal mail, please send a check or money order with the corresponding Notice of Payment Information below.
- Use the following document to submit identifying vendor information with your payment:
Note: Paper applications with identifying vendor information must be mailed to the ACB at:
CDSS – ACB
744 P Street, MS 9-15-807
Sacramento, CA 95814
ATTN: Vendor Support and Review Unit
Forms:
LIC 9141 – Vendor Application/Renewal – An individual, for profit or nonprofit business or governmental entity submits this form to request ACB 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 ACB review and approval of a new or updated course.
LIC 9140A – Request to Add or Replace Instructor – Vendors use this form to request ACB approval to add or replace an instructor of an approved course.
LIC 9139 – Renewal of Continuing Education Course Approval – Vendors submit this form for ACB 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 ACB names of course participants.