Please rate Lic 215 Form 12-22
List all experiences and periods of unemployment in the last seven years.
Work experience: begin with your most recent work experience. Include work experience from more than seven years, if necessary.
References: please give references, including present and past employers, with knowledge of your administrative ability.
Declaration: I declare under penalty of perjury that the statements on this form are correct to the best of my knowledge.
More space: if more space is required, attach additional sheet.
| Question | Answer |
|---|---|
| Form Name | LIC 215 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 141 |
| Avg. time to fill out | 24 min |
| Edition | 12/22 |
| Issuing agency | California Department of Social Services |
| Who completes it | All applicants for a facility license |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | LIC 215, LIC215, 215 form, Form LIC 215, HS 215A, Applicant Information |
| Official source | LIC 215 (Rev 12/22), California Department of Social Services |
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Please rate Lic 215 Form 12-22
