Form Lic 281 - Application Instructions For A Facility License Page 4
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22A1.
LIC 200 - APPLICATION FOR A COMMUNITY CARE FACILITY OR RESIDENTIAL CARE FACILITY
FOR THE ELDERLY LICENSE.
•
Make sure the form is filled out completely.
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All applicants must sign the application, including each general partner.
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The application should contain original signatures. The licensing agency will not accept
photocopied signatures on this form.
•
If the application indicates that the applicant previously held a license for a facility, the licensing
agency will compare the Applicant Information Form (LIC 215), and verify that the applicant is
not subject to disciplinary action.
•
Signatures should match applicant’s name, unless the application is a corporation or limited
liability company. (See below).
•
If a corporation is applying for the license, all persons signing the application must be authorized
by the Board resolution and the Board resolution must be submitted with this form.
NOTE:
For partnerships, corporations and limited liability companies – See SECTION B. criteria for
additional information below.
A2.
LIC 215 - APPLICANT INFORMATION
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There should be a form completed by each applicant.
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If the applicant previously held a license, held a beneficial ownership of 10 percent or more or
was an administrator, general partner, corporate officer or director of a licensed facility, the
licensing agency will research to determine if the applicant is subject to disciplinary action.
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This form will be used as necessary to verify qualifications when an applicant also intends to be
the Administrator/Director.
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The form must contain original signatures. The licensing agency will not accept photocopied
signatures on this form. Reference statements must be current and should not be from relatives.
A3.
LIC 308 - DESIGNATION OF FACILITY RESPONSIBILITY
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At least one individual must be designated as the authorized person of the facility to act in the
licensee’s absence. A LICENSEE CANNOT DESIGNATE HIM OR HERSELF. More than one staff
person may be designated on a form.
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If the applicant is a corporation or a limited liability company, a resolution must authorize the
delegation and be submitted with this form.
•
The form must contain the original signatures of the applicants/licensees. The licensing agency
will not accept photocopied signatures on this form.
A4.
LIC 309 - ADMINISTRATIVE ORGANIZATION
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Individual applicants are NOT required to complete this form.
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This form must be completed if the applicant is a corporation, public agency, partnership, or
limited liability company.
•
Make sure the information matches that on the application (LIC 200).
•
Terms of office should match articles/bylaws.
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