Vendor Application/renewal - State Of California - Health And Human Services Agency Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING DIVISION

Printed Name:

Social Security Number:*

(6) Do you currently hold or have you previously held a license, certification or other approval as a professional in a specified field

YES

(e.g., RN, NHA)? If yes, please list the type(s) of license(s) or certificate(s) and their number(s). (Include any Administrator

Certificates.)

(7) Do you currently hold or have you previously held a State-issued care facility license? If yes, please list the type of license(s) and

YES

license number(s). (Include any community care facility licenses.)

(8) Are you currently employed or were you previously employed by a State-licensed care facility? If yes, please list the facility

YES

name(s) and license number(s). (Place an * by those where currently employed.)

(9) Have you been the subject of any legal, administrative, or other action involving licensure, certification or other approvals as

YES

specified in (6), (7), and (8) above? If yes, please explain and provide the date(s). (Include any Administrative Actions. Attach

additional pages if more space is needed.)

(10) I declare that the foregoing information is true and correct to the best of my knowledge.

Signature

Date

Printed Name:

Social Security Number:*

(6) Do you currently hold or have you previously held a license, certification or other approval as a professional in a specified field

YES

(e.g., RN, NHA)? If yes, please list the type(s) of license(s) or certificate(s) and their number(s). (Include any Administrator

Certificates.)

(7) Do you currently hold or have you previously held a State-issued care facility license? If yes, please list the type of license(s) and

YES

license number(s). (Include any community care facility licenses.)

(8) Are you currently employed or were you previously employed by a State-licensed care facility? If yes, please list the facility

YES

name(s) and license number(s). (Place an * by those where currently employed.)

(9) Have you been the subject of any legal, administrative, or other action involving licensure, certification or other approvals as

YES

specified in (6), (7), and (8) above? If yes, please explain and provide the date(s). (Include any Administrative Actions. Attach

additional pages if more space is needed.)

(10) I declare that the foregoing information is true and correct to the best of my knowledge.

Signature

Date

Printed Name:

Social Security Number:*

(6) Do you currently hold or have you previously held a license, certification or other approval as a professional in a specified field

YES

(e.g., RN, NHA)? If yes, please list the type(s) of license(s) or certificate(s) and their number(s). (Include any Administrator

Certificates.)

(7) Do you currently hold or have you previously held a State-issued care facility license? If yes, please list the type of license(s) and

YES

license number(s). (Include any community care facility licenses.)

(8) Are you currently employed or were you previously employed by a State-licensed care facility? If yes, please list the facility

YES

name(s) and license number(s). (Place an * by those where currently employed.)

YES

(9) Have you been the subject of any legal, administrative, or other action involving licensure, certification or other approvals as

specified in (6), (7), and (8) above? If yes, please explain and provide the date(s). (Include any Administrative Actions. Attach

additional pages if more space is needed.)

(10) I declare that the foregoing information is true and correct to the best of my knowledge.

Signature

Date

* Optional but requested for CDSS use only to assist in verifying identity and licensing affiliations. Federal law (at Title 5 United States Code Section 552a Note) states that:

Any federal, state, or local government agency which requests an individual to disclose his social security account number shall inform that individual whether that

disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.

LIC 9141 (1/16)

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