Lic 500 Form PDF Details

In order to obtain your license, you will need to fill out the Lic 500 form. This document is used to collect all of the necessary information required by the Department of Licensing and Regulatory Affairs (LARA). The form can be completed online or on paper, but be sure to have all of the required documents handy before you start. Once you have filled out the form, be sure to submit it along with your application and fee. Your license should arrive in the mail within a few weeks.

Below are some facts you might want to go over before you begin dealing with the lic 500 form.

QuestionAnswer
Form NameLic 500 Form
Form Length2 pages
Fillable?Yes
Fillable fields547
Avg. time to fill out36 min 38 sec
Other namesstate of california lic forms, license form 500, lic 500 pdf, lic 500 form

Form Preview Example

STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONNEL REPORT

INSTRUCTIONS: This form is intended for keeping a current roster of all the facility personnel, other adults and licensees residing in the facility, including backup persons, volunteers and licensee if administrator/director. Show license/certificate number if applicable for specialized staff [e.g., Social Worker and other consultant(s)]. Show coverage for twenty-four hour supervision in residential facilities. Report any changes in personnel to the licensing agency as required by regulations. Send original to Licensing Agency and retain copy in facility file.

NAME OF FACILITY

FACILITY TYPE

FACILITY NUMBER

PREPARED BY

DATE

A.STAFF SUBJECT TO CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following staff members are subject to a criminal background check pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. A California background clearance or a criminal record exemption shall be obtained prior to employment, residence or initial presence in the facility.

 

DATE

 

 

SPECIFY

 

 

SPECIFY

 

 

SPECIFY

 

NAME

JOB TITLE

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

EMPL'D

 

 

DAYS

FROM

TO

DAYS

FROM

TO

DAYS

FROM

TO

 

 

 

Licensee/Administrator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIC 500 (11/03) (PUBLIC)

Page 1 of 2

B.STAFF EXEMPT FROM CRIMINAL BACKGROUND CHECK REQUIREMENTS: The following are believed exempt from criminal background check requirements pursuant to Sections 1522, 1568.09, 1569.17 and 1596.871 of the Health and Safety Code. The licensee or designated representative shall sign below to verify that he or she believes the indicated persons are exempt from criminal background check requirements pursuant to statute.

Signature ________________________________________________________________________________ Date __________________

NAME

DATE

EMPL'D

JOB TITLE

 

SPECIFY

 

 

SPECIFY

 

 

SPECIFY

 

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS AND HOURS ON DUTY

DAYS

FROM

TO

DAYS

FROM

TO

DAYS

FROM

TO

 

 

 

 

 

 

 

 

 

Page 2 of 2

How to Edit Lic 500 Form Online for Free

Our top rated developers have worked together to get the PDF editor you are going to begin using. This software makes it simple to obtain lic 500 community care licensing documentation instantly and efficiently. This is certainly all you need to do.

Step 1: The first thing will be to click the orange "Get Form Now" button.

Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu.

For every single segment, fill out the content requested by the software.

lic 500 11 03 public fields to complete

Note the essential details in the space LICPUBLIC, and Pageof.

Completing lic 500 11 03 public part 2

Note down the required information when you find yourself within the SignatureDate, NAME, DATE, EMPLD, JOBTITLE, SPECIFY, SPECIFY, SPECIFY, DAYSANDHOURSONDUTY, DAYSANDHOURSONDUTY, DAYSANDHOURSONDUTY, DAYS, FROM, DAYS, and FROM area.

lic 500 11 03 public SignatureDate, NAME, DATE, EMPLD, JOBTITLE, SPECIFY, SPECIFY, SPECIFY, DAYSANDHOURSONDUTY, DAYSANDHOURSONDUTY, DAYSANDHOURSONDUTY, DAYS, FROM, DAYS, and FROM fields to complete

The Pageof area will be used to write down the rights or obligations of both sides.

Filling in lic 500 11 03 public step 4

Step 3: Press the "Done" button. It's now possible to upload your PDF file to your electronic device. Additionally, you can deliver it by means of email.

Step 4: In order to prevent probable upcoming challenges, you need to obtain at least a few copies of every document.

Watch Lic 500 Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .