Fillable Form 3: APPLICANT INFORMATION (California)

Fill Online, Printable, Fillable, Blank Form 3: APPLICANT INFORMATION (California) Form

Use Fill to complete blank online CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 3: APPLICANT INFORMATION (California)

On average this form takes 38 minutes to complete

The Form 3: APPLICANT INFORMATION (California) form is 2 pages long and contains:

  • 0 signatures
  • 36 check-boxes
  • 136 other fields

Country of origin: US
File type: PDF

BROWSE CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
APPLICANT INFORMATION
This form must be completed by all applicants for a facility license, (i.e., all individuals, each partner in a partnership, or chief executive officer or
authorized representative in a corporation.) If more space is required, attach additional sheet. Type or print clearly.
IDENTIFYING INFORMATION
NAME SOCIAL SECURITY NUMBER
(VOLUNTARY FOR I.D. ONLY)
*
SEX (M/F) ARE YOU 18 YEARS OR OLDER?
TITLE DRIVER’S LICENSE NUMBER VALID
■ Ye s ■ No
PLACE OF BIRTH
ADDRESS
(AREA CODE) TELEPHONE NUMBER
( )
OTHER NAME(S) USED BY APPLICANT
EDUCATION
3
7 9 10 11 12
4 8
2
6
5
Check highest completed grade:
1
NAME AND LOCATION OF HIGH SCHOOL
DATE COMPLETED GED DATE
NAME AND LOCATION OF COLLEGE
COURSE STUDY YEARS COMPLETED
1
2 3 4
DEGREE DATE COMPLETED
1
2 3
4
REFERENCES
PERSONAL:
(PLEASE GIVE REFERENCES, INCLUDING PRESENT AND PAST EMPLOYERS, WITH KNOWLEDGE OF YOUR ADMINISTRATIVE ABILITY.)
NAME
1.
ADDRESS RELATIONSHIP TELEPHONE
2.
FINANCIAL:
(PLEASE GIVE REFERENCES WITH KNOWLEDGE OF FINANCIAL RESOURCES AND BUSINESS PRACTICES.)
NAME
1.
ADDRESS RELATIONSHIP TELEPHONE
2.
PRIOR LICENSURE STATUS
A. HAVE YOU EVER BEEN A LICENSEE OR CO-LICENSEE OF A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,
COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY?
■ YES ■ NO
IF YES,, COMPLETE C AND D BELOW.
B. HAVE YOU EVER HELD A BENEFICIAL OWNERSHIP OF 10% OR MORE IN A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,
COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY OR BEEN AN ADMINISTRATOR, GENERAL PARTNER, CORPORATE
OFFICER, OR DIRECTOR OF ANY SUCH FACILITY?
■ YES ■ NO
IF YES, COMPLETE C AND D BELOW:
C. NAME AND ADDRESS OF FACILITY EFFECTIVE DATES OF LICENSURE
_________________ __________________
FACILITY TYPE
TO
D. WERE ANY DISCIPLINARY ACTIONS TAKEN?
■ YES ■ NO
IF YES, PLEASE EXPLAIN:
BUSINESS EXPERIENCE
A. HAVE YOU OWNED OR OPERATED ANY BUSINESS? ■ YES ■ NO
IF YES, COMPLETE THE FOLLOWING:
Type
Number of
Employees
Your Title
Date
Started
Date
Ended
Reason for End
B. DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE? ■ YES ■ NO
IF YES, COMPLETE THE FOLLOWING:
Type Period Held Issuing Agency
C. ARE YOU A MEMBER OF ANY PROFESSIONAL/TECHNICAL ASSOCIATION? ■ YES ■ NO
IF YES, COMPLETE THE FOLLOWING:
Association Name Address
LIC 215 (7/04) (PERSONAL)
■ ■
WORK EXPERIENCE. BEGIN WITH YOUR MOST RECENT WORK EXPERIENCE. LIST ALL EXPERIENCES AND PERIODS OF
UNEMPLOYMENT IN THE LAST SEVEN YEARS. INCLUDE WORK EXPERIENCE FROM MORE THAN SEVEN YEARS, IF NECESSARY.
Dates Name and Address of Employer Basic Duties Termination Reason
FROM
TO
FROM
TO
FROM
TO
FROM
TO
FROM
TO
PERSONAL INFORMATION
A.
Do you have any physical, mental, or medical condition that could impair your ability to care for the type of resident/client for whom you have requested licensure?
■
YES
■
NO
If yes, please explain:
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE
COUNTY WHERE SIGNED DATE
* Federal law (at Title 5 United States Code Section 552a Note) states that:
Any Federal, State, or local government agency which requests an individual to disclose his social security account number shall inform that individual whether
that disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 3: APPLICANT INFORMATION (California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document