Type or Print First and Last Name
STATE OF CALIFORNIA |
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FOR DEPARTMENT USE ONLY |
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BUSINESS, TRANSPORTATION AND HOUSING AGENCY |
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DTN #: |
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DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT |
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Received Date: |
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DIVISION OF CODES AND STANDARDS |
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OCCUPATIONAL LICENSING PROGRAM |
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Approved By: |
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APPLICATION FOR INSTRUCTOR RENEWAL |
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Disapproved By: |
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Date: |
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SECTION 1 – APPLICANT INFORMATION |
(Type or Print) |
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APPROVAL NUMBER: __________________________________ |
TELEPHONE NUMBER: (_____) _____________________ |
NAME: __________________________________________________________________________________________________________________________ |
Last |
First |
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Middle |
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ADDRESS: ___________________________________________________________________________________________________________________________ |
Number and Street |
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City |
State |
ZIP Code |
MAILING ADDRESS (If different): _________________________________________________________________________________________________________
Number and Street or P.O. BoxCityStateZIP Code
E-MAIL ADDRESS (If applicable): ______________________________________________________________________________________________________
SECTION 2 – PERSONAL HISTORY (Type or Print)
1.Have you been issued any license for the sale of MH-Units or commercial modulars, either as a dealer, salesperson, or manufacturer since your original application for instructor approval was filed? YES_____ NO_____
If yes, list below the license number, license type, and expiration date of each license issued.
License Number ___________________________ |
Expiration Date __________________________ |
State _________________ |
License Number ___________________________ |
Expiration Date __________________________ |
State _________________ |
License Number ___________________________ |
Expiration Date __________________________ |
State _________________ |
2.Excluding traffic offenses, have you ever been convicted, fined or placed on probation/parole for any crime or offense, either felony or
misdemeanor, since your original Application for Instructor Approval was filed? |
YES_____ NO_____ |
If yes, list each separate offense below. If you are currently on probation or parole, show the name and address of your probation officer.
NOTE: A background investigation will be made, and failure to disclose ALL convictions, fines or probations including those out- of-state and expunged, may result in a refusal to approve your application.
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DISPOSITION OF OFFENSE |
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DATE OF |
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COURT OF JURISDICTION |
(DESCRIBE SENTENCE) |
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ARREST |
NATURE OF OFFENSE |
(FULL NAME AND ADDRESS) |
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Amount |
Term of |
Jail or |
Date |
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Fined |
Probation/Parole |
Prison Term |
Released |
□CHECK IF ADDITIONAL PAGE(S) IS/ARE ATTACHED TO ANSWER QUESTIONS
SECTION 3 – APPLICANT CERTIFICATION
I, ____________________________________________________________, certify under penalty of perjury under the laws of the State of
California that the answers and information contained herein are true and correct to the best of my knowledge and belief.
SIGNATURE ______________________________________________ TITLE ____________________________ DATE _______________
EXECUTED IN THE COUNTY OF _________________________________________________________ STATE OF __________________
SUBMIT APPLICATION AND THE FEE SPECIFIED IN THE CALIFORNIA CODE OF REGULATIONS, TITLE 25, SECTION 5360 FOR APPLICATION FOR INSTRUCTOR RENEWAL TO:
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT DIVISION OF CODES AND STANDARDS
OCCUPATIONAL LICENSING PROGRAM P. O. BOX 31
SACRAMENTO, CA 95812-0031
HCD OL ED 132 (Rev. 06/09)
