Renewal License Application For A Health Care Institution Page 2
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9RENEWAL LICENSE APPLICATION FOR A HEALTH CARE INSTITUTION
ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH LICENSING SERVICES - BUREAU OF MEDICAL FACILITIES LICENSING
II. OWNER INFORMATION
Owner’s Name:
Street Address:
City:
State:
Zip Code:
Phone No.
Fax No
The owner is a (select one):
Sole proprietorship
Corporation
Partnership
Limited liability partnership
Governmental agency
Limited liability company
If the owner is a partnership or a limited liability partnership, the name of each partner;
If the owner is a limited liability company, the name of the designated manager or, if no manager is designated, the
names of any two members of the limited liability company;
If the owner is a corporation, the name and title of each corporate officer; or
If the owner is a governmental agency, the name and title of the individual in charge of the governmental agency or
the name of an individual in charge of the health care institution designated in writing by the individual in charge of
the governmental agency:
Name:
Title:
Title:
Name:
Title:
Name:
Has the owner or any person with 10% or more business interest in the health care institution had a
license to operate a health care institution denied, revoked, or suspended since the previous license application was
submitted?
YES
NO
If yes, indicate:
The reason for denial, revocation, or suspension:
The date of the denial, revocation, or suspension:
The name and address of the licensing agency that denied, revoked, or suspended the license or certification:
Page 2
Rev. 5/23/16
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