SECTION 4 – LLC PERSONNEL FULL LEGAL NAMES AND ADDRESSES (Other than Qualifying Individual)
The following must be completed by all individuals who will be listed on the license. You must provide full legal names of all individuals. Each individual must
sign the certification under penalty of perjury. (The definition of “perjury” is telling a lie while under oath.)
9a. PERSONNEL FULL LEGAL NAME Last First Middle DATE OF BIRTH SOCIAL SECURITY NUMBER
RESIDENCE ADDRESS Number/Street Only – NO P.O. Boxes or PMBs City State ZIP Code DRIVER LICENSE #
TITLE OR POSITION (check only one)
□ Member □ Manager □ Officer - Title(s)
RESIDENCE PHONE NUMBER
( )
I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all
supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax
Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name
9b. PERSONNEL FULL LEGAL NAME Last First Middle DATE OF BIRTH SOCIAL SECURITY NUMBER
RESIDENCE ADDRESS Number/Street Only – NO P.O. Boxes or PMBs City State ZIP Code DRIVER LICENSE #
TITLE OR POSITION (check only one)
□ Member □ Manager □ Officer - Title(s)
RESIDENCE PHONE NUMBER
( )
I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all
supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax
Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name
9c. PERSONNEL FULL LEGAL NAME Last First Middle DATE OF BIRTH SOCIAL SECURITY NUMBER
RESIDENCE ADDRESS Number/Street Only – NO P.O. Boxes or PMBs City State ZIP Code DRIVER LICENSE #
TITLE OR POSITION (check only one)
□ Member □ Manager □ Officer - Title(s)
RESIDENCE PHONE NUMBER
( )
I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all
supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax
Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name
9d. PERSONNEL FULL LEGAL NAME Last First Middle DATE OF BIRTH SOCIAL SECURITY NUMBER
RESIDENCE ADDRESS Number/Street Only – NO P.O. Boxes or PMBs City State ZIP Code DRIVER LICENSE #
TITLE OR POSITION (check only one)
□ Member □ Manager □ Officer - Title(s)
RESIDENCE PHONE NUMBER
( )
I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all
supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax
Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name
(If additional space is needed, please make a copy of this blank page.)
FOR CSLB USE ONLY
13A-10d (10/11)
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