Get Lic 9165a

The Lic 9165a form is essential for all board members of group homes to acknowledge their legal responsibilities. This guide provides clear and detailed instructions on how to fill out the form online, ensuring all users can complete it accurately and efficiently.

Follow the steps to fill out the Lic 9165a form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the facility name as it is registered. This ensures proper identification of the board member with the correct corporate licensee.
3. Next, input the facility number. Ensure that all board members use the same facility number for consistency and verification.
4. In the subsequent fields, clearly print or type your name. This should be your full legal name as it will appear in official records.
5. Provide your daytime telephone number so that you can be contacted if necessary. Make sure the number is current and accessible.
6. Complete your mailing address, ensuring that all components—street, city, state, and zip code—are accurately filled out.
7. In the signature field, add your original signature. This confirms your understanding and agreement to the responsibilities outlined in the publication.
8. Finally, enter the date when you are signing the form. It should reflect the current date of completion.
9. Once all fields are completed, review your form for accuracy and completeness.
10. Save your changes, and then download, print, or share the completed form as necessary.

Complete your Lic 9165a form online to ensure compliance today.