Form Lic 9139 - Renewal Of Continuing Education Course Approval - Administrator Certification Program

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RENEWAL OF CONTINUING EDUCATION COURSE APPROVAL
ADMINISTRATOR CERTIFICATION PROGRAM
Instructions: To renew an approved course, vendors must submit this completed form, along with their vendor renewal application
(LIC 9141) to CDSS, ACS, 744 “P” Street, MS 9-14-47, Sacramento, CA 95814, at least 60 days in advance of the course expiration.
Submit a separate application for each program type (ARF, GH, RCFE), and copy the form as needed to list all the courses proposed for
renewal. Note that if a course’s content is being modified, do not include it on this form; use form LIC 9140.
I
I
I
I
(1) Type of Program and Vendorship: (Select one box.)
ARF CEU
GH CEU
RCFE CEU
STRTP
(735-2)
(730-2)
(740-2)
(733-2
)
(2)Vendor Information: (Please print.)
Vendor Number:
_________________________________________________
Organization/Vendor Business Name:____________________________________________________________________________
Authorized Representative/Contact Person (Name):
________________________________________________________________________
Business Phone Number: ____________________ Fax:_______________________ E-mail: __
_________________________________
(3) Course Information: (Please print course names and numbers in columns (A) and (B).)
FOR ACS USE ONLY
FOR VENDOR USE
NEW
DISAPPROVAL
EFFECTIVE
(A)
(B)
EXPIRATION
DATE
COURSE NAME(S) AS CURRENTLY APPROVED
COURSE NUMBER(S)
DATE OF
(xxx-xxxx-xxxxx)
DATE
APPROVAL
(4) Vendor Certification: We are requesting to renew and continue offering the currently-approved courses listed above. We assure
that the course content, classroom hours, and instructor(s) are the same as currently approved, and that the content is still current and
accurate. Should any changes in the course content, instructor(s) or hours occur, we will submit a new course approval form to the ACS
for approval prior to conducting the revised course. Schedules and rosters will be submitted as required by CDSS.
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
Title
Date
DO NOT WRITE BELOW THIS LINE
Reviewed by
Date
LIC 9139 (11/16)

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