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Get CA LIC 215 2004

WERE ANY DISCIPLINARY ACTIONS TAKEN FACILITY TYPE TO HAVE YOU OWNED OR OPERATED ANY BUSINESS BUSINESS EXPERIENCE Number of Employees Type IF YES PLEASE EXPLAIN DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE ARE YOU A MEMBER OF ANY PROFESSIONAL/TECHNICAL ASSOCIATION Association Name LIC 215 7/04 PERSONAL Date Started Your Title Ended Period Held Reason for End Issuing Agency Address WORK EXPERIENCE. BEGIN WITH YOUR MOST RECENT WORK EXPERIENCE. LIST ALL EXPERIENCES AND PERIODS OF UNEMPLOYMENT IN THE LAST SEVEN YEARS. INCLUDE WORK EXPERIENCE FROM MORE THAN SEVEN YEARS IF NECESSARY. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION APPLICANT INFORMATION This form must be completed by all applicants for a facility license i*e* all individuals each partner in a partnership or chief executive officer or authorized representative in a corporation* If more space is required attach additional sheet. Type or print clearly. IDENTIFYING INFORMATION NAME SOCIAL SECURITY NUMBER VOLUNTARY FOR I. D. ONLY TITLE DRIVER S LICENSE NUMBER SEX M/F VALID Yes ARE YOU 18 YEARS OR OLDER PLACE OF BIRTH No AREA CODE TELEPHONE NUMBER ADDRESS OTHER NAME S USED BY APPLICANT EDUCATION Circle highest completed grade NAME AND LOCATION OF HIGH SCHOOL COURSE STUDY YEARS COMPLETED DATE COMPLETED GED DATE DEGREE REFERENCES PERSONAL PLEASE GIVE REFERENCES INCLUDING PRESENT AND PAST EMPLOYERS WITH KNOWLEDGE OF YOUR ADMINISTRATIVE ABILITY. RELATIONSHIP TELEPHONE FINANCIAL PLEASE GIVE REFERENCES WITH KNOWLEDGE OF FINANCIAL RESOURCES AND BUSINESS PRACTICES* PRIOR LICENSURE STATUS A. HAVE YOU EVER BEEN A LICENSEE OR CO-LICENSEE OF A RESIDENTIAL CARE FACILITY FOR THE ELDERLY YES NO IF YES COMPLETE C AND D BELOW* B. C. HAVE YOU EVER HELD A BENEFICIAL OWNERSHIP OF 10 OR MORE IN A RESIDENTIAL CARE FACILITY FOR THE ELDERLY OFFICER OR DIRECTOR OF ANY SUCH FACILITY EFFECTIVE DATES OF LICENSURE NAME AND ADDRESS OF FACILITY D. Name and Address of Employer Basic Duties Termination Reason FROM TO PERSONAL INFORMATION Do you have any physical mental or medical condition that could impair your ability to care for the type of resident/client for whom you have requested licensure If yes please explain I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE* SIGNATURE COUNTY WHERE SIGNED DATE Federal law at Title 5 United States Code Section 552a Note states that Any Federal State or local government agency which requests an individual to disclose his social security account number shall inform that individual whether that disclosure is mandatory or voluntary by what statutory or other authority such number is solicited and what uses will be made of it. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION APPLICANT INFORMATION This form must be completed by all applicants for a facility license i*e* all individuals each partner in a partnership or chief executive officer or authorized representative in a corporation* If more space is required attach additional sheet. Type or print clearly. IDENTIFYING INFORMATION NAME SOCIAL SECURITY NUMBER VOLUNTARY FOR I. D. ONLY TITLE DRIVER S LICENSE NUMBER SEX M/F VALID Yes ARE YOU 18 YEARS OR OLDER PLACE OF BIRTH No AREA CODE TELEPHONE NUMBER ADDRESS OTHER NAME S USED BY APPLICANT EDUCATION Circle highest completed grade NAME AND LOCATION OF HIGH SCHOOL COURSE STUDY YEARS COMPLETED DATE COMPLETED GED DATE DEGREE REFERENCES PERSONAL PLEASE GIVE REFERENCES INCLUDING PRESENT AND PAST EMPLOYERS WITH KNOWLEDGE OF YOUR ADMINISTRATIVE ABILITY. .

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