California Lic 309 Details

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.

Here is the data concerning the form you were in search of to fill in. It can show you the length of time you will need to complete lic 309, exactly what fields you will need to fill in, and so forth.

QuestionAnswer
Form NameLic 309
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslic 309, 309 administrative organization, lic 309 pdf, 309 administrative

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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 By-Laws or Operating Agreement and any amendments (3) A copy of Resolution authorizing the filing of this application (for Corporations only).

6.Principal office of business:

Address

City

Zip Code

County

Telephone No.

Contact Person:

Title:

 

Telephone No.:

 

7. Out of state or foreign applicants complete the following:

 

 

 

a. Name of California Representative

 

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

(other than facility address)

 

 

Telephone No.

Term Expires

President

Vice-President

Secretary

Treasurer

LIC 309 (6/01) (PUBLIC)

11.List all Directors (Corporations)/Managers and Managing Members (LLC)

Name

 

Mailing Address & City & Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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: _____________________________________________________________________________________________________________

 

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

 

 

 

 

TELEPHONE NUMBER

 

Limited

Principal Business Address

 

 

 

 

CITY/STATE

2nd Partner

General

Name

 

 

 

 

TELEPHONE NUMBER

 

Limited

Principal Business Address

 

 

 

 

CITY/STATE

3rd Partner

General

Name

 

 

 

 

TELEPHONE NUMBER

 

Limited

Principal Business Address

 

 

 

 

CITY/STATE

4th Partner

General

Name

 

 

 

 

TELEPHONE NUMBER

 

Limited

Principal Business Address

 

 

 

 

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.