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-3B – ADMINISTRATIVE ORGANIZATION - PUBLIC AGENCIES, PARTNERSHIPS, SOLE PROPRIETOR, AND
Check type of public age
Name of agency providin
Attach a copy of Resolution or other legal document authorizing this application.
City and Zip Code
Attach a copy of the partnership agreement.
SOLE PROPRIETOR/OTHER ASSOCIATIONS
Sole Proprietors/other associations must also provide a list of all person(s) legally responsible for the organization.
USE A SEPARATE SHEET FOR ADDITIONAL NAMES
Attach all appropriate legal documents (fictitious name statement, business license) which set forth legal responsibility
of the organization and accountability for opening the program.
DHCS 5084 (01/15)