Form Dhcs 3007 Personal Background History Statement Page 2
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4State of California – Health and Human Services Agency
Department of Health Care Services
Name of Applicant: _______________________________
Facility No: __________________
PART II: LICENSE, CERTIFICATE, AND PERMIT STATEMENT
License/Certificate/Permit Type:
Mental Health Professional
Medical Professional
Other Professional
Unlicensed Staff
Current License/Certificate/Permit Name: ____________________________________________________
Current License/Certificate/Permit Number: ____________________________________________________
Issue Date: ______________________
Expiration Date: ________________________
State of Current License, Certificate, or Permit: _________________________________________________
1. Do you have or have you ever had any administrative action taken against you by a federal, state or local
government agency (e.g. denial, suspension, probation, or revocation of a license, permit, or certificate
and or disciplinary action)?
Yes
No
a. If you answer “yes” to question 1, please describe the nature and circumstance of any administrative
action, the location, and date. (Use additional sheets of paper, if needed.)
2. Is there any pending administrative action taken against you by any federal, state or local government
agency, such as a disciplinary action or pending investigation against your license, certificate, or permit?
Yes
No
a. If you answer “yes” to Question 2, please describe the nature and circumstance of any pending
administrative action, disciplinary action or pending investigation, the location, and date such
action or investigation began. (Use additional sheets of paper, if needed.)
DHCS 3007 (02/15)
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