Form Lic 9141 - Vendor Application/renewal - Administrator Certification Program Page 2
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1
2STATE 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
I
I
YES
NO
specified field (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
I
I
YES
NO
license(s) and 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 name(s) and license number(s). (Place an * by those where currently employed.)
I
I
YES
NO
(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.)
I
I
YES
NO
(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
I
I
YES
NO
specified field (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
I
I
YES
NO
license(s) and 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 name(s) and license number(s). (Place an * by those where currently employed.)
I
I
YES
NO
(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.)
I
I
YES
NO
(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
I
I
YES
NO
specified field (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
I
I
YES
NO
license(s) and 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 name(s) and license number(s). (Place an * by those where currently employed.)
I
I
YES
NO
(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.)
I
I
YES
NO
(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 (6/16)
PAGE 2 OF 2
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