Hospital Certificate Of Approval Page 14
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18F-62092 (Rev. 07/08)
Page 14
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Street
Begin Date
City
State
Zip Code
Ownership Percentage
I. OWNER OF LAND
Complete this section if the owner of the land is not the same entity as the owner of the operation or the owner of the
building.
Holding:
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
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