________________________
State of California — Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
A-2 – ADMINISTRATOR/DIRECTOR INFORMATION
IDENTIFYING INFORMATION
NAM E
TITLE:
TELEPHONE NUMBER
E-MAIL ADDRESS:
ADDRESS:
OTHER NAME(S) USED BY ADMINISTRATOR/DIRECTOR:
EDUCATION
T HE HIGHEST
GRADE LEVEL YOU
C OMPLETED 1 2 3 4 5 6 7 8 9 10 11 12:
HIGH SCHOOL GRADUATE: YES NO
PASSED HIGH SCHOOL
EQUIVALENCY
TESTS: YES
NAM
E AND LOCATION
OF
COLLEGE OR UNIVERSITY
COURSE OF
STUDY
COMPLETED
SEMESTER
UNITS
QUARTER
UNITS
DEGREE
OBTAINED
DATE
COMPLETED
MANAGEMENT EXPERIENCE
Type
Title
Date
Started
Date
Ended
Reason for Leaving
DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE?
YES
NO
IF YES, COMPLETE THE FOLLOWING:
Type Period Held Issuing Agency
WORK EXPERIENCE
BEGIN WITH YOUR MOST RECENT WORK EXPERIENCE. LIST ALL EXPERIENCE WHICH INDICATES COMPLIANCE
WITH LICENSING REGULATIONS AND/OR CERTIFICATION STANDARDS.
Dates
Name and Address of
Em
ployer
Duties
Reason for Leaving
FROM
TO
FROM
TO
FROM
TO
:
:
Signature:
Date:
DHCS 5082 (01/15)
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signature
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