Roster Of Participants - For Vendor Use Only- Ictp Or Ceu Courses - State Of California - Health And Human Services Agency
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ROSTER OF PARTICIPANTS–FOR VENDOR USE ONLY- ICTP OR CEU COURSES
ADMINISTRATOR CERTIFICATION PROGRAM
Instructions: Upon ACS request, vendors must submit a copy of the complete roster of participants to CDSS, ACS, 744 “P” Street, MS 9-14-47, Sacramento, CA 95814.
Copy this form as needed for additional space. For ICTPs, have a separate roster for each day. Keep the originals for your files.
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(1) Type of Program and Vendorship: (Select one box.)
ARF ICTP
GH ICTP
RCFE ICTP
STRTP ICTP
ARF CEU
GH CEU
RCFE CEU
STRTP CEU
(735-1)
(730-1)
(740-1)
(725-1)
(735-2)
(730-2)
(740-2)
(725-2)
(2) Vendor and Course Information: (Please print.) Organization/Business Name: ______________________________________________________ Vendor #: _________________________________
Course Name: ______________________________________________________ Date: _________________________________________ Location: ________________________________________
Instructor Names(s): __________________________________________________________________________ CEU Course #: _________________________________________________________
(3) Participant Roster: (Please print.)
Last Name of Participant (Print)
First Name & Middle Initial of Participant
Phone Number
Facility Name or Facility License #
Time In
Address
City
Zip Code
E-mail Address
Time out
Last Name of Participant (Print)
First Name & Middle Initial of Participant
Phone Number
Facility Name or Facility License #
Time In
Address
City
Zip Code
E-mail Address
Time out
Last Name of Participant (Print)
First Name & Middle Initial of Participant
Phone Number
Facility Name or Facility License #
Time In
Address
City
Zip Code
E-mail Address
Time out
Last Name of Participant (Print)
First Name & Middle Initial of Participant
Phone Number
Facility Name or Facility License #
Time In
7
Address
City
Zip Code
E-mail Address
Time out
Last Name of Participant (Print)
First Name & Middle Initial of Participant
Phone Number
Facility Name or Facility License #
Time In
Address
City
Zip Code
E-mail Address
Time out
Last Name of Participant (Print)
First Name & Middle Initial of Participant
Phone Number
Facility Name or Facility License #
Time In
Address
City
Zip Code
E-mail Address
Time out
(4) Vendor Certification: I declare that the foregoing information is true and correct to the best of my knowledge.
Signature of Vendor/Authorized Representative
Printed Name of Vendor /Authorized Representative
Date
Total # Roster Pages
Title
enclosed:
LIC 9142A (5/16)
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