The Lic 309 form is a document used to report the license of an individual or business. This form is used by organizations, businesses and government institutions to keep track of licenses held by individuals or businesses. The Lic 309 form can be used for a variety of reasons, such as verifying the validity of a license or locating a particular license holder. The Lic 309 form must be completed in full and submitted to the appropriate authority. Failure to submit this form may result in penalties or other legal action.
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| Question | Answer |
|---|---|
| Form Name | Lic 309 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | lic 309, 309 administrative organization, lic 309 pdf, 309 administrative |
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
ADMINISTRATIVE ORGANIZATION
(This side is for corporations and limited liability companies only. See reverse for public agencies, partnerships, and other associations.)
INSTRUCTIONS: This form must be updated and submitted to the Licensing Agency each time there is a change in partners, officers or changes in the corporation or limited liability company as provided in the Callifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2).
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
DATE
FACILITY NAME
FACILITY ADDRESS
FACILITY NUMBER
I. CORPORATION/LIMITED LIABILITY COMPANY (LLC)
1. Name (as filed with Secretary of State)
2.Chief Executive Officer
3.Incorporation/Registration Date
4.Place of Incorporation/Registration
Corporation/Limited Liability Company Number
5.Please attach (1) A copy of Articles of Incorporation or organization and any amendments (2) A copy of
6.Principal office of business:
Address |
City |
Zip Code |
County |
Telephone No. |
Contact Person: |
Title: |
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Telephone No.: |
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7. Out of state or foreign applicants complete the following: |
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a. Name of California Representative |
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Address |
Zip Code |
Telephone No. |
b.Please attach a copy of a foreign corporation’s or foreign LLC’s registration to do business in California.
8.Names and addresses of all persons who own ten percent (10%) or more interest in corporation or LLC. Attach sheet for additional space.
9.Directors (Corporation)/Managers and Managing Members (LLC)
a.Number of Directors/Managers & Managing Members
b.Term of Office (if applicable)
c.Frequency of Meetings (if applicable)
d.Method of Selection (corporations only)
10.Officers: (For LLCs without officers, skip this section and go to Section II)
Office |
Name |
Principal Business Address & City & Zip Code |
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(other than facility address) |
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Telephone No.
Term Expires
President
Secretary
Treasurer
LIC 309 (6/01) (PUBLIC)
11.List all Directors (Corporations)/Managers and Managing Members (LLC)
Name |
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Mailing Address & City & Zip Code |
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Telephone No.
Term Expires
(Attach Sheet for additional space)
II.PUBLIC AGENCY
1. Check type of public agency: |
■ Federal |
■ State |
■ County |
■ City |
■ Other, specify below |
2.Agency providing services:
Name: _______________________________________________ Address: ___________________________________________________________
CITY/STATE
Mailing Address: _____________________________________________________________________________________________________________
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CITY/STATE/ZIP CODE |
Contact Person: __________________________________ |
Title: ___________________________________ Phone No.:_______________________ |
3.District or Area to be served: (attach map if necessary)
Specify geographic area:
4.Attach copy of Resolution or legal document authorizing this application.
III.PARTNERSHIPS
Attach a copy of partnership agreement (attach additional sheet if necessary)
1st Partner |
■ General |
Name |
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TELEPHONE NUMBER |
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■ Limited |
Principal Business Address |
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CITY/STATE |
2nd Partner |
■ General |
Name |
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TELEPHONE NUMBER |
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■ Limited |
Principal Business Address |
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CITY/STATE |
3rd Partner |
■ General |
Name |
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TELEPHONE NUMBER |
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■ Limited |
Principal Business Address |
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CITY/STATE |
4th Partner |
■ General |
Name |
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TELEPHONE NUMBER |
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■ Limited |
Principal Business Address |
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CITY/STATE |
Contact Person: _______________________________ Title: __________________________________ Telephone No.: ___________________
IV. OTHER ASSOCIATIONS
Other associations must also provide a similar list of persons legally responsible for the organization, contact person, appropriate legal documents which set forth legal responsibility of the organization and accountability for operating the facility.