Form Lic 309 - Administrative Organization
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ADMINISTRATIVE ORGANIZATION
DATE
(This side is for corporations and limited liability companies only. See reverse for public agencies,
partnerships, and other associations.)
FACILITY NAME
INSTRUCTIONS:
This form must be updated and submitted to the Licensing Agency each time there is a change
FACILITY ADDRESS
in partners, officers or changes in the corporation or limited liability company as provided in the
Callifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2).
FACILITY NUMBER
I. CORPORATION/LIMITED LIABILITY COMPANY (LLC)
1.
Name (as filed with Secretary of State)
2.
Chief Executive Officer
4.
Place of Incorporation/Registration
Corporation/Limited Liability Company Number
3.
Incorporation/Registration Date
5.
Please attach (1) A copy of Articles of Incorporation or organization and any amendments (2) A copy of By-Laws or Operating Agreement and any
amendments (3) A copy of Resolution authorizing the filing of this application (for Corporations only).
6. Principal office of business:
Address
City
Zip Code
County
Telephone No.
Contact Person:
Title:
Telephone No.:
7. Out of state or foreign applicants complete the following:
a. Name of California Representative
Address
Zip Code
Telephone No.
b. Please attach a copy of a foreign corporation’s or foreign LLC’s registration to do business in California.
8. Names and addresses of all persons who own ten percent (10%) or more interest in corporation or LLC. Attach sheet for additional space.
9. Directors (Corporation)/Managers and Managing Members (LLC)
a.
Number of Directors/Managers & Managing Members
b.
Term of Office (if applicable)
c.
Frequency of Meetings (if applicable)
d.
Method of Selection (corporations only)
10. Officers: (For LLCs without officers, skip this section and go to Section II)
Principal Business Address & City & Zip Code
Office
Name
Telephone No.
Term Expires
(other than facility address)
President
Vice-President
Secretary
Treasurer
LIC 309 (6/01) (PUBLIC)
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