Lic 9165 Form PDF Details

Understanding and filling out Lic 9165 form can be a complex process. It's important to get it right, as incorrect information can lead to steep penalties or costly administrative delays when applying for certain licenses and permits with the California Department of Fish and Wildlife (CDFW). In this blog post, we'll provide you with an overview of the Lic 9165 form and what you need to know in order to fill it out correctly. We'll cover topics such as where you can find a copy of the form, what types of information are needed, how long it takes for processing, fees associated with completing the application, and more!

QuestionAnswer
Form NameLic 9165 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesLicensees, licensee, LIC, ensures

Form Preview Example

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

BOARD OF DIRECTOR STATEMENT

IMPORTANT– Before completing, see reverse for instructions.

Licensees are required to provide a copy of the Community Care Licensing’s publication, Facts You Need To Know, Group Home Board of Directors, to each member of their board of directors. The members of the board of directors are required to read and sign the statement below. This form must be completed by all board members. The signing of this form by all members, and prospective members, of the board of directors is a condition of licensure.

I have read and understand my legal duties and obligations as a member of the board of directors and I also understand that the group home’s operation is governed by laws and regulations that are enforced by the Department of Social Services, as set forth in the publication, Facts You Need To Know, Group Home Board of Directors.

I declare that I have received a copy and I have read and understand the information contained in the publication, Facts You Need To Know, Group Home Board of Directors.

1.

Facility Name

 

2.

Facility Number

 

 

 

 

 

 

3.

Your Name (Print Clearly)

 

4.

Daytime Telephone No.

 

 

 

 

 

 

5.

Your Mailing Address

6. City

7.

State

8. Zip

 

 

 

 

 

 

9.

Signature

 

10.

Date

 

 

 

 

 

 

 

Note: The publication, Facts You Need To Know, Group Home Board of Directors booklet is only as current as the initial publishing date or any later revision date. Therefore, the booklet may not include information on the most current law and regulation changes that you may need to know. Boards of directors should ensure that they are informed of law and regulation changes.

LIC 9165 (2/99)

BOARD OF DIRECTOR STATEMENT

INSTRUCTIONS

General Information

As stated on the front side, each member of the board of directors must sign this form. Also, prospective board members must read the Group Home Board of Directors booklet and sign this form before joining the board. This form may be copied and given to each of your members for their signature. The signed forms must be kept at the group home’s administrative office. The signed forms must be available to licensing staff for inspection upon request.

Instructions

Please type or clearly print the information being requested by each item number.

Items 1. and 2. Enter the facility name and number. When a corporate licensee has more than one facility, it is important that the same facility number is used for all board members. This ensures that each and all board members are associated and identified with the correct corporate licensee. It is acceptable to enter this on behalf of the board member.

Items 3.-10.The board member enters his or her name, daytime telephone number, complete mailing address, signature and date. All signatures must be original.

I have read and understand my legal duties and obligations as a member of the board of directors and I also understand that the group home’s operation is governed by laws and regulations that are enforced by the Department of Social Services, as set forth in the publication, Facts You Need To Know, Group Home Board of Directors.

How to Edit Lic 9165 Form Online for Free

By using the online editor for PDFs by FormsPal, you can easily complete or alter LICENSING here. Our development team is ceaselessly endeavoring to expand the editor and ensure it is much better for people with its many features. Take your experience one step further with continually growing and unique options available today! It merely requires a couple of simple steps:

Step 1: Click the "Get Form" button above on this webpage to open our PDF editor.

Step 2: When you open the online editor, you will see the document ready to be completed. In addition to filling out various fields, you can also perform various other actions with the PDF, including putting on your own text, editing the initial text, inserting illustrations or photos, putting your signature on the PDF, and more.

This form will need specific details to be entered, hence be sure to take your time to type in exactly what is requested:

1. It is very important complete the LICENSING properly, thus be careful while working with the areas that contain these specific blanks:

Stage # 1 for submitting lic9165a

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