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-3A – ADMINISTRATIVE ORGANIZATION – CORPORATIONS
INSTRUCTIONS: Attach a copy of approved articles of incorporation papers from the Secretary of State. This form
m
ust be updated and submitted to the Department of Health Care Services each time there is a change in officers
or change in the corporation.
CORPORATION
Name
(as listed with the Secretary of State):
Incorporation Date:
Place of Incorporation
:
Chief Executive Officer:
Principal Office of Business Address:
City:
Zip Code:
Contact Person:
Title:
Telephone:
Names and addresses of all persons who own ten percent (10%) or more of stock in corporation:
Name
Address
Governing Board of Directors:
Number of Board Members:
Term of Office:
Frequency of Meetings:
Method of Selection:
Board Officers and Members
Office
Name
Business Address, City &
Zip Code
Telephone
Number
Term Expire
Date
President
Vice
P
resident
Secretary
Treasurer
Other
Other
Other
USE A SEPARATE SHEET FOR ADDITIONAL NAMES
DHCS 5083 (01/15)
