Hospital Certificate Of Approval Page 13
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18F-62092 (Rev. 07/08)
Page 13
Name
Telephone Number
Address
City
State
Zip Code
Name
Telephone Number
Address
City
State
Zip Code
H. OWNER OF BUILDING / LAND
If the building, land, or building and land, is owned by an entity (i.e., corporation, partnership, individual, etc.) other than
I
the applicant / owner, complete this section. If the owner of the land is another entity, also complete Section
.
Holding:
Building
Land
Name
Telephone Number
Mailing Address
Fax Number
City
County
State
Zip Code
Type Of Organization
Check type of ownership.
Governmental
Proprietary
Voluntary Non-Profit
City
Sole Proprietary
Corporation
County
Partnership
Church
State
Corporation
Association
Federal
Limited Liability Company
Church / Corporation
City / County
Limited Liability Partnership
Private Non-Profit
Tribal
Trust
Limited Liability Company
Limited Liability Partnership
Trust
Interested Parties
Definition: Interested parties are (1) persons or business entities having ownership interest of 5% or more, (2) partners
if the entity is a partnership, (3) officers and directors if the entity is a corporation, and (4) if the entity is either
governmental or non-profit, interested parties are the officers and directors. If there is a separate listing already in
existence, and that listing contains all the required information, attach a copy of that listing to this application. If a
complete listing is attached, completion of this portion of the application will be considered satisfied.
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
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