Lic 9215 Form PDF Details

In order to conduct business in the state of California, you may need to apply for a state license. One such license is the Lic 9215 form. This form is used to apply for a contractor's license, and it can be used by individuals or businesses. The process of obtaining a contractor's license can be daunting, but with the help of this guide, you'll be able to complete the application process easily. Keep in mind that requirements may vary depending on your specific situation, so be sure to consult with the appropriate authorities before submitting your application.

You can find details about the type of form you would like to submit in the table. It can show you just how long it may need to complete lic 9215 form, exactly what fields you will have to fill in, and so on.

Form NameLic 9215 Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameslic 9214, lic 9215 application for administrator certification, rcfe renewal application form, renew rcfe

Form Preview Example

744 P Street, MS 9-14-47, Sacramento, CA 95814



Certificate #:

Effective Date:

Expiration Date:



City, State, Zip Code:

This letter is to notify you that the administrator certificate issued to you by the California Department of Social Services (CDSS) will expire in 90 days. In order to maintain compliance with the provisions of the Administrator Certification Program, you are required to submit your renewal information and fee prior to the certificate expiration date. Please submit the following:

1.Copy of certificate(s) of completion of required continuing education.

A total of (40) forty hours of continuing education is required if you are an Administrator for either a Residential Care Facility for the Elderly, an Adult Residential Facility or a Group Home. If you are a Nursing Home Administrator, (20) twenty hours of continuing education are required.

Hours may be completed through any combination of courses provided by:

CDSS approved Vendors.

Department of Developmental Services and approved by the Regional Center for ARF and GH Administrators (Regional Center Orientation(s) and/or challenge tests are not acceptable).

Accredited educational institutions and vendors approved by other California State Agencies provided such courses are consistent with the Core of Knowledge specified in Regulations. You must submit each course with certificate of completion and a description of the course(s) or it will be returned to you. If the course does not relate to the Core of Knowledge or is duplicative (you have taken the identical course before), it will not be credited toward the recertification requirement.

Crisis Prevention Institute, Inc. (CPI), “Nonviolent Crisis Intervention” training. Pocket size certificates must be accompanied with a letter from CPI (approved by the Board of Behavioral Sciences). The refresher course(s) is not acceptable for CEUs.

2.Processing fee of $100. If your certificate has expired and/or your application is deemed incomplete, you will be required to pay an additional $200.

You must have an active criminal record clearance on file with the Department. If you do not have an active clearance on file, you will be informed in writing on how to proceed.


LIC 9215 (12/12)



NAME (Please print):_________________________________________________________________________________




1.Do you currently possess or have you previously held a license, certification or other approval as a professional in a specified field? If yes, please indicate the type of license or certificate and license number(s);



License Number: _______________ Certificate Number: ___________________

2.Do you currently hold or have you previously held a government issued facility license to operate or provide services to individuals? If yes, please indicate the type of license or certificate and license number(s);

Yes NoLicense Number: _______________ Certificate Number: ___________________

Issuing Government Agency: _______________________________________________

3.Are you currently or were you previously employed by a licensed community care facility? If yes, please indicate the facility name(s) and license number(s);



Facility Name: __________________

License Number: ______________________



Facility Name: __________________

License Number: ______________________



Facility Name: __________________

License Number: ______________________

4.Have you been the subject of any administrative, legal or other action involving licensure, certification or other approvals as specified in (1), (2) or (3) above? If yes, please explain and provide dates. If additional space is needed, please attach to this application form.

Yes No

I declare under penalty of perjury that the foregoing information is true.

Applicant Signature (MANDATORY): _____________________________________________ Date: ____________________

This application for renewal must be post-marked on or before the certificate expiration date. Please mail to: California Department of Social Services, Administrator Certification Section, 744 P Street, M.S. 9-14-47, Sacramento, CA 95814.

If you have any questions regarding this form, please contact the Community Care Licensing Division, Administrator Certification Section at (916) 653-9300.

LIC 9215 (12/12)


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