Lic 9215 form-2026

1. Click ‘Get Form’ to open the lic 9215 form in the editor.
2. Begin by entering your personal information in the designated fields, including your name, address, and certificate details. Ensure accuracy as this information is crucial for processing.
3. In Section 1, indicate whether you currently possess or have previously held a license or certification. If yes, provide the type and number of the license.
4. Proceed to Section 2 and answer if you hold or have held a government-issued facility license. Fill in the required details if applicable.
5. For Section 3, state your employment status with any licensed community care facilities. List their names and license numbers as needed.
6. In Section 4, disclose any administrative or legal actions related to your licensure. Provide explanations and dates if necessary.
7. Finally, sign and date the application at the bottom of Page 2 before submitting it to ensure compliance with renewal requirements.

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