Loading
Get Ca Cdph 414 2013-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the CA CDPH 414 online
This guide provides a comprehensive walkthrough for completing the CA CDPH 414 application for health facility or agency change of location. Follow these instructions to ensure that your application is filled out accurately and efficiently.
Follow the steps to successfully complete the CA CDPH 414 online.
- Click the ‘Get Form’ button to access the CA CDPH 414 form and open it in your online editor.
- In Section A, Current Facility Information, fill in the name of the facility, the type of facility, the current street address, and the city, state, and zip code. Additionally, indicate the days and hours of operation.
- Move to Section B, Licensee Information. Enter the full legal name of the licensee, including titles if applicable, and the license number. Include the federal employer's tax ID number, licensee street address, city, state, zip, telephone number, fax number, and email address.
- Proceed to Section C, Facility, Agency or Clinic New Location Information. Enter the new street address, city, state, and zip. Provide the telephone number, fax number, and email address. If there is a different pay-to address, include that information as well.
- Indicate if construction is required by checking 'Yes' or 'No'. If 'Yes', provide the construction start and completion dates and submit documentation to show compliance with building requirements.
- Enter the name of the person in charge of the facility, agency, or clinic.
- In Section D, Property Information, provide the name and address of the owner of record, lessee, and sub-lessee as applicable. Attach the necessary documentation such as grant deeds or leases.
- Conclude by signing the application, ensuring that the application is signed by the licensee or an authorized representative. Review the entire form for accuracy and completeness.
- Once completed, save your changes and download or print the application for your records. Share the form as needed with the appropriate authorities.
Start your application process by competing the CA CDPH 414 online without delay.
Filling out a debit authorization form involves providing your bank information and agreeing to recurring payments. Ensure that you have read all terms to secure your financial details. The uslegalforms site offers a helpful guide and template specifically for the CA CDPH 414, ensuring you complete the form correctly.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.