Form LIC 215 at a glance
What it is: The Applicant Information form (LIC 215) of the California Department of Social Services.
Who signs: Sign, and enter the County where Signed and the Date.
All applicants for a facility license complete this form, that is all individuals, each partner in a partnership, and the chief executive officer or authorized representative in a corporation. If more space is required, attach an additional sheet. Type or print clearly.
A filled-in Form LIC 215 example: a first-time applicant with no prior license
How to fill out Form LIC 215, box by box
Identifying information
Enter your Name, Social Security Number and Sex (M/F), and Are you 18 years or older?
Enter your Title and Driver's License Number, and mark Yes or No under Valid.
Enter your Place of Birth, Address and Telephone Number.
Enter Other Name(s) Used by Applicant, and Applicant Preferred Language (Not Required).
Education
Enter the Highest Completed Grade.
For high school, enter the Name and Location of High School, Date Completed and GED Date.
For college, enter the Name and Location of College, Course Study, Years Completed, Degree and Date Completed.
References
Under PERSONAL, give references, including present and past employers, with knowledge of your administrative ability: enter the Name, Address, Relationship and Telephone for reference 1 and for reference 2.
Under FINANCIAL, give references with knowledge of financial resources and business practices: enter the Name, Address, Relationship and Telephone for reference 1 and for reference 2.
Prior licensure status
A. Have you ever been a Licensee or Co-Licensee of a residential Care Facility for the Elderly, Community Care, Child Care or Health Facility? Mark YES or NO.
B. Have you ever held a beneficial Ownership of 10% or more in a Residential Care Facility for the Elderly, Community Care, Child Care or Health Facility or been an Administrator, General Partner, Corporate Officer, or Director of any such Facility? Mark YES or NO.
If Yes to A or B, fill in C and D. For C, enter the Name and Address of Facility, the Effective Dates of Licensure and the Facility Type.
For D, mark YES or NO to Were any disciplinary actions taken? If yes, please explain.
Business experience
A. Have you owned or operated any business? Mark Yes or No. If Yes, complete the following: Type, Number of Employees, Your Title, Date Started, Date Ended and Reason for End.
B. Do you have a professional License or Certificate? Mark Yes or No. If Yes, complete the following: Type, Period Held and Issuing Agency.
C. Are you a member of any Professional/Technical Association? Mark Yes or No. If Yes, complete Association Name and Address.
Work experience
Begin with your most recent work experience.
List all experiences and periods of unemployment in the last seven years.
Include work experience from more than seven years, if necessary.
For each employer, enter the Dates (From and To), Name and Address of Employer, Basic Duties and Termination Reason.
Personal information
A. Do you have any physical, mental, or medical condition that could impair your ability to care for the type of resident/client for whom you have requested licensure? Mark Yes or No. If Yes, explain.
Signing under penalty of perjury
By signing you declare under penalty of perjury that the statements on this form are correct to the best of your knowledge.
Sources
[1] Form LIC 215 (12/22), Applicant Information, California Department of Social Services (the Official source link on this page).
