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OTHER ASSOCIATIONS A-3B ADMINISTRATIVE ORGANIZATION - PUBLIC AGENCIES, (Department of Health Care Services)

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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
OTHER ASSOCIATIONS
PUBLIC AGENCY
Check type of public age
ncy:
County
City
Other, specify:
Name of agency providin
g service:
Address:
City:
Zip Code:
Contact Person:
Title:
Telephone:
Attach a copy of Resolution or other legal document authorizing this application.
PARTNERSHIPS
Contact Person:
Title:
Telephone:
Partners
Type of
Pa
rtnership
Partner Name
Business Address
City and Zip Code
1st Par
t
ner
General
Limited
2nd Partner
General
Limited
3rd Partner
General
Limited
4th Partner
General
Limited
Attach a copy of the partnership agreement.
SOLE PROPRIETOR/OTHER ASSOCIATIONS
Contact Person:
Title:
Telephone:
Sole Proprietors/other associations must also provide a list of all person(s) legally responsible for the organization.
Name
Title
Telephone
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)
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OTHER ASSOCIATIONS A-3B ADMINISTRATIVE ORGANIZATION - PUBLIC AGENCIES, (Department of Health Care Services)

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Completed 23 November 2020

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