Lic 215 2025

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142 votes

The document is an application form for individuals seeking a facility license from the California Department of Social Services. It requires personal information, educational background, work experience, references, prior licensure status, and any medical conditions that may affect the applicant's ability to care for residents. The form emphasizes the need for accurate information under penalty of perjury.

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Click ‘Get Form’ to open the lic 215 in the editor.
Begin by filling out the Applicant Information section. Enter your name, social security number (optional), title, and driver's license number. Ensure all details are typed clearly.
In the Identifying Information section, indicate your sex and confirm if you are 18 years or older. Provide your place of birth and contact number.
Complete the Education section by circling the highest grade completed and listing your high school and college information, including course study and degrees obtained.
Provide references in both Personal and Financial sections. Include names, addresses, relationships, and telephone numbers for each reference.
Answer questions regarding prior licensure status honestly. If applicable, provide details about previous licenses held and any disciplinary actions taken.
Fill out the Work Experience section with your employment history over the last seven years, detailing duties and reasons for termination.
Finally, declare under penalty of perjury that all statements are correct by signing at the bottom of the form.

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2004	4.8 Satisfied (142 Votes)

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