LIC 301E at a glance
What it is: LIC 301E is the REFERENCE REQUEST - EXEMPTION form of the California Department of Social Services.
Who signs: Print Your Name, add Your Signature and the Date.
The named person has applied to operate, work or reside in a community care facility serving the client group indicated and has selected you to write a reference statement on his/her behalf. 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.
A filled-in LIC 301E example: a neighbor writes a reference
How to fill out LIC 301E, box by box
Reference request for and Facility Type
Enter the REFERENCE REQUEST FOR line and the Facility Type.
You must enter your full name and facility type before you give this form to your reference for completion.
Your Name and address
Enter Your Name, Street Address, City, State, Zip and Day Time Telephone Number.
How long have you known the person and how do you know this person
1. How long have you known the person you are writing this reference for?
2. How do you know this person?
Opinion of this person's character, interaction observed and comments
3. Please give your opinion of this person's character.
4. Please describe any interaction you have observed between this person and the client group he/she is requesting to work with. For example: Clients may be children, developmentally disabled children or adults, mentally impaired adults, or elderly.
5. Please add any comments you feel are relevant about this person and his/her desire to work in a community care facility.
Print Your Name, Your Signature and Date
Print Your Name, add Your Signature and the Date.
More rules for LIC 301E
Complete the entire form.
Sources
[1] LIC 301E Reference Request - Exemption (10/22), California Department of Social Services (the Official source link on this page).
