Fillable RENEWAL OF CONTINUING EDUCATION COURSE APPROVAL ADMINISTRATOR CERTIFICATION (California)

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RENEWAL OF CONTINUING EDUCATION COURSE APPROVAL ADMINISTRATOR CERTIFICATION (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RENEWAL OF CONTINUING EDUCATION COURSE APPROVAL
ADMINISTRATOR CERTIFICATION PROGRAM
Instructions: To renew an approved course, vendors must submit this completed form, along with
their vendor renewal application (LIC 9141) to CDSS, ACS, 744 “P” Street, MS 9-17-47, Sacramento,
CA 95814, at least 60 days in advance of the course expiration. Submit a separate application for
each program type (ARF, GH, RCFE), and copy the form as needed to list all the courses proposed
for renewal. Note that if a course’s content is being modified, do not include it on this form; use form
LIC 9140.
(1) Type of Program and Vendorship: (Select one box.)
☐ARF CEU (735-2)
☐ GH CEU (730-2)
☐ RCFE CEU (740-2)
☐ STRTP CEU (733-2)
(2) Vendor Information: (Please print.)
Vendor Number: ___________________________________________________________________
Individual/Organization/Vendor Business Name: __________________________________________
Vendorship Expiration Date: __________________________________________________________
Authorized Representative (Full Name): ________________________________________________
Phone Number: ___________________________________________________________________
Fax: ____________________________________________________________________________
E-mail: __________________________________________________________________________
(3) Course Information: [Please print course names and numbers in columns (A) and (B).]
FOR ACS USE ONLY FOR VENDOR USE ONLY
DISAPPROVAL
DATE
EFFECTIVE
DATE OF
APPROVAL
NEW
EXPIRATION
DATE
(A)
COURSE NAME(S) AS
CURRENTLY APPROVED
(B)
COURSE
NUMBER(S)
(xxx-xxxx-xxxxx)
DISAPPROVAL
DATE
EFFECTIVE
DATE OF
APPROVAL
NEW
EXPIRATION
DATE
(A)
COURSE NAME(S) AS
CURRENTLY APPROVED
(B)
COURSE
NUMBER(S)
(xxx-xxxx-xxxxx)
(4) Vendor Certification: We are requesting to renew and continue offering the currently-approved
courses listed above. We assure that the course content, classroom hours, and instructor(s) are the
same as currently approved, and that the content is still current and accurate. Should any changes in
the course content, instructor(s) or hours occur, we will submit a new course approval form to the
ACS for approval prior to conducting the revised course. Schedules and rosters will be submitted as
required by CDSS.
I declare that the foregoing information is true and correct to the best of my knowledge.
Signature of Vendor/Authorized
Representative
Title
Reviewed by
DO NOT WRITE BELOW THIS LINE
LIC 9139 (11/16)
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RENEWAL OF CONTINUING EDUCATION COURSE APPROVAL ADMINISTRATOR CERTIFICATION (California)

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Completed 5 June 2021

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