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Y FILE NUMBER . PERSONAL NAME (LAST FIRST TELEPHONE MIDDLE) ADDRESS ARE YOU 18 YEARS OF AGE OR OLDER? IF NO, PLEASE STATE YOUR AGE u NO u YES SOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY) DATE OF LAST PHYSICAL EXAMINATION HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME? DO YOU POSSESS A VALID CAUFORNIA DRIVER'S LICENSE? u u YES YES u u NO DATE OF LAST TB TEST IF YES, PLEASE LIST ALL NAMES USED. NO HAS YOUR DRIVERS LICENSE EVER BEEN SUSPENDED OR REVOKED? CDL NUMBER NEAR.

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INSTRUCTIONS: This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director.

You must give the following information on the LIC 500 form: Employer information: The form must include the employer's name, address, and telephone number. Each employee's name and social security number. Dates of the pay period. Total number of hours worked by each employee during the pay period.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232