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Get CA HHSA DSS LIC 9142A 2016

ATOR CERTIFICATION PROGRAM Instructions: Upon ACS request, vendors must submit a copy of the complete roster of participants to CDSS, ACS, 744 “P” Street, MS 9-14-47, Sacramento, CA 95814. Copy this form as needed for additional space. For ICTPs, have a separate roster for each day. Keep the originals for your files. (1) Type of Program and Vendorship: (Select one box.) ■ ARF ICTP (735-1) ■ GH ICTP (730-1) ■ RCFE ICTP ■ ARF CEU (740-1) (735-2) ■ GH CEU ■ RCFE CEU (730-2).

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