Please rate Lic 301E 10-22
If you work at the facility, are a client of the facility, or are related to this person in any way, you may not complete this reference statement.
Before the reference: you must enter your full name and facility type before you give this form to your reference for completion.
Complete: please complete the entire form.
Character: please give your opinion of this person's character.
Client group: please describe any interaction you have observed between this person and the client group he/she is requesting to work with.
| Question | Answer |
|---|---|
| Form Name | Form LIC 301E |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 19 |
| Avg. time to fill out | 4 min |
| Edition | 10/22 |
| Issuing agency | California Department of Social Services |
| Who signs | The reference |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | LIC 301E, LIC301E, 301E, Form LIC 301E, Reference Request - Exemption, LIC 301E reference request form |
| Official source | Form LIC 301E (Rev 10/22), California Department of Social Services |
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Please rate Lic 301E 10-22
