Form Dhcs 5082 - California Administrator/director Information - 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-2 – ADMINISTRATOR/DIRECTOR INFORMATION
IDENTIFYING INFORMATION
NAME
TITLE
TELEPHONE NUMBER
E-MAIL ADDRESS
(
)
ADDRESS
OTHER NAME(S) USED BY ADMINISTRATOR/DIRECTOR
EDUCATION
YES □ NO □
EDUCATION
CIRCLE THE HIGHEST GRADE YOU COMPLETED
HIGH SCHOOL GRADUATE
PASSED HIGH SCHOOL EQUIVALENCY TESTS YES □
1 2 3 4 5 6 7 8 9 10 11 12
COMPLETED
NAME AND LOCATION OF
COURSE OF
DEGREE
DATE
SEMESTER QUARTER
COLLEGE OR UNIVERSITY
STUDY
OBTAINED
COMPLETED
UNITS
UNITS
MANAGEMENT EXPERIENCE
Type
Title
Date
Date
Reason for Leaving
Started
Ended
□
□
DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE?
Yes
No
IF YES, COMPLETE THE
FOLLOWING
Type
Period Held
Issuing Agency
WORK EXPERIENCE. BEGIN WITH YOUR MOST RECENT WORK EXPERIENCE. LIST ALL EXPERIENCE WHICH
INDICATES COMPLIANCE WITH LICENSING REGULATIONS AND/OR CERTIFICATION STANDARDS.
Dates
Name and Address of
Duties
Reason for Leaving
Employer
FROM
TO
FROM
TO
FROM
TO
Signature:
Date: ________________________
DHCS 5082 (07/13)
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