Get Lic 9215 Form

Filling out the Lic 9215 Form online is an essential step for administrators seeking to renew their certification. This guide will walk you through the process, ensuring you complete each section accurately and efficiently.

Follow the steps to successfully fill out the Lic 9215 Form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering your certification details, including certificate number, effective date, and expiration date. Ensure the information matches the documentation you have.
3. Fill in your personal information, including your name, address, city, state, and zip code. This information is crucial for identification.
4. Indicate whether you currently possess or have previously held a license or certification in a specified field by selecting 'Yes' or 'No.' If 'Yes,' provide the type and number of your license.
5. Next, answer if you hold or have held a government-issued facility license. Again, if applicable, provide the details of the license or certificate.
6. Confirm your employment status with any licensed community care facility by answering similarly. Provide the names of the facilities and their corresponding license numbers if applicable.
7. Answer whether you have experienced any administrative or legal actions involving your licensure. If 'Yes,' provide a brief explanation and necessary dates. Attach additional documentation if needed.
8. Complete the applicant signature section by signing your name and entering the date. This is mandatory to validate your application.
9. Once all fields are completed, review your inputs for accuracy. You can then save your changes, download the form for future reference, print it, or share it as needed.

Complete your Lic 9215 Form online today to ensure your renewal process is seamless.