Get CA LIC 9141 2016
, please list the type(s) of license(s) or certificate(s) and their number(s). (Include any Administrator Certificates.) I YES I NO (7) Do you currently hold or have you previously held a State-issued care facility license? If yes, please list the type of license(s) and license number(s). (Include any community care facility licenses.) I YES I NO (8) Are you currently employed or were you previously employed by a State-licensed care facility? If yes, please list the facility name(s) and lice.
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