Administrator Certification Section Forms

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

Administrator Forms:

LIC 9214Application 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! The ACS 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 ACS 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 ACS 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 Section – 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.

Note:  Paper applications with identifying vendor information must be mailed to the ACS at:

CDSS – ACS
744 P Street, MS 9-17-47
Sacramento, CA 95814
ATTN: Vendor Support and Review Unit

Forms:

LIC 9141Vendor 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 9139 – Renewal 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 9142ARoster 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.