Get Lic 9011 A - Cdss Ca

Understanding how to properly complete the LIC 9011 A - Cdss Ca form is essential for facilitating effective communication with the California Department of Social Services. This guide provides clear, step-by-step instructions to help users fill out the form accurately and efficiently online.

Follow the steps to complete the LIC 9011 A - Cdss Ca online effectively.

1. Press the ‘Get Form’ button to access the LIC 9011 A - Cdss Ca form and open it in the form editor.
2. In the 'Data Summary Section,' provide the type of facility in the designated field. Ensure the information reflects the current operation of your facility.
3. Enter the facility name clearly in the appropriate field to identify the location associated with this form.
4. Fill in the individual’s name in the next section, along with any known aliases (AKA) in the corresponding field.
5. Complete the facility address by including the street address, city, state, and zip code, ensuring all details are accurate.
6. Provide the individual's date of birth in the specified format to confirm their identity.
7. Include the facility number assigned to your establishment in the required field.
8. Fill in the CII number and any other facility numbers as applicable, ensuring consistency with your records.
9. Provide the individual's social security number (SS No.) in the designated field.
10. Identify the licensing office and its address, ensuring it corresponds with the relevant jurisdiction.
11. Fill in the driver’s license number (DL No.) and provide physical characteristics such as height and eye color.
12. Designate a contact person by entering their name clearly.
13. State the individual's place of birth for record verification.
14. Input the individual’s telephone number for any follow-up inquiries.
15. Indicate the individual’s relationship to the facility by checking the appropriate box (licensee/applicant, employee, resident, relative, or other).
16. Make note of any relevant legal information as required, including attorney details and legal case number if applicable.
17. Respond to the questions about license revocation, application denial, or client contact denial by selecting 'yes' or 'no' and providing effective dates where necessary.
18. Complete the employee address field, if applicable, to ensure accurate contact information.
19. Document any probation details, including terms and dates, if pertinent.
20. Add any additional comments or notes in the comments section for further clarification.
21. Once all fields are completed, review the information for accuracy. Save your changes, download or print the form, or share it as needed.

Begin completing your LIC 9011 A - Cdss Ca form online now for a smoother submission process.