Department of Social Services
744 P Street, MS T9-15-62
Sacramento, CA 94814
User Information (to be completed by Licensee)
Licensee Name (First and Last)
Phone Number
E-Mail Address
Please Note: The email address listed will be utilized as your Username for Guardian.
SYSTEM ACCESS: Please list all facilities in which you are the Licensee and need Guardian
access for. Utilize back of page if you need additional space.
Facility Number: Facility Name:
User Acknowledgments and Signature
This section is to be read and completed by the user prior to receiving access to any CDSS
system(s) and/or application(s).
I acknowledge that the department will grant Guardian access to me as specified in this document. I
will use the system for appropriate business purposes. I will take reasonable precautions to protect
the confidential and sensitive data in the system.
I certify under penalty of perjury; I am the Licensee and the information provided is true and
correct to the best of my knowledge.
Licensee Name (Print)
Licensee Signature
Return Instructions: Completed forms may be faxed to (916) 754-4589, emailed to, or mailed to: