Get Lic 9141 (304) Vendor Applicationrenewal - Administrator Certification Program - Dss Cahwnet

Filling out the LIC 9141 (304) form for the Vendor Application/Renewal under the Administrator Certification Program is an essential step for applicants seeking certification. This guide provides clear, step-by-step instructions to assist users in completing the form effectively and efficiently online.

Follow the steps to successfully complete the LIC 9141 (304) form online.

1. Press the ‘Get Form’ button to access the LIC 9141 (304) document and open it in your preferred online editing tool.
2. Begin by selecting the type of program you are applying for by checking the appropriate box — options include Residential Care Facility for the Elderly (RCFE), Adult Residential Facility (ARF), or Group Home (GH).
3. Indicate the type of application by selecting either 'New' or 'Renewal.' If it is a renewal, provide the vendor approval number and the LIC 9139 if applicable.
4. Choose the type of vendor you are registering as by checking the relevant box — options include 35/40 Hour Vendor or CEU Vendor, noting any associated processing fees.
5. Fill in the organization or vendor name, the contact person or authorized representative's name, and the vendor mailing address (including street address, city, state, and zip code).
6. Select the category that describes the vendor type by checking the corresponding box, including options such as individual, partnership, corporation, university, or governmental agency.
7. List all individuals, contact persons, or board members, stating their titles. Each listed individual must complete the back of the form.
8. Complete the declaration under penalty of perjury by printing the name of the vendor or authorized representative, signing, and providing the title and date.
9. If applicable, answer questions regarding any prior licenses or employments, and provide information about administrative or legal actions related to licensure.
10. Review the completed form for accuracy and clarity, ensuring all required fields are filled out correctly.
11. Finalize by saving changes to the document, and you can then download, print, or share the form as needed.

Complete your LIC 9141 (304) Vendor Application/Renewal online today for a smooth certification process.