Form Dhcs 5084 - California Administrative Organization Public Agencies, Partnerships, Sole Proprietor, And Other Associations - Health And Human Services Agency
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1State of California — Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
A-3B – ADMINISTRATIVE ORGANIZATION - PUBLIC AGENCIES, PARTNERSHIPS, SOLE PROPRIETOR, AND
OTHER ASSOCIATIONS
PUBLIC AGENCY
1. Check type of public agency: □ County
□ City
□Other, specify:
2. Agency providing service
Name:
Address:
City:
Zip Code:
Contact Person:
Title:
Telephone:
3. Attach a copy of Resolution or other legal document authorizing this application
PARTNERSHIPS
1. Attach a copy of the partnership agreement
2. Partners
Type of
Name
Business Address
Partnership
City and Zip Code
□ General
□ Limited
1st Partner
□ General
□ Limited
2nd Partner
□ General
□ Limited
3rd Partner
□ General
□ Limited
4th Partner
Contact Person: _
Title:
Telephone #:
SOLE PROPRIETOR/OTHER ASSOCIATIONS
Sole Proprietors/other associations must also provide a list of all person(s) legally responsible for the organization,
the contact person, and appropriate legal documents (fictitious name statement, business license) which set forth
legal responsibility of the organization and accountability for opening the program. Use the following space or attach
a separate sheet.
DHCS 5084 (07/13)
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