Lic 9215 form-2026

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The document is an application for administrator re-certification issued by the California Department of Social Services. It outlines the requirements for renewing an administrator certificate, including submission of continuing education hours, a processing fee, and maintaining an active criminal record clearance. The application must be completed and submitted before the certificate expiration date.

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Click ‘Get Form’ to open the lic 9215 form in the editor.
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.
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.
Proceed to Section 2 and answer if you hold or have held a government-issued facility license. Fill in the required details if applicable.
For Section 3, confirm your employment status with a licensed community care facility. List any relevant facilities along with their license numbers.
In Section 4, disclose any administrative or legal actions related to your licensure. Provide explanations and dates as necessary.
Finally, ensure you sign and date the application at the bottom before submitting it to the California Department of Social Services.

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How to download LIC surrender form?

Step 1: Visit LICs official website. Step 2: Sign in using your credentials. Step 3: Download the Surrender Discharge Voucher (LIC Form No. 5074).

What is a LIC 602 form?

Form 602 is issued by the California Department of Social Services. The form was established as a way to help senior communities better understand the needs of potential residents in terms of medical assistance, nutritional needs, mental and physical capabilities and other care requirements.

Which form is required for a LIC maturity claim?

Maturity Claims: Please submit your Discharged Receipt in Form No.3825 with original policy document atleast one month before the due date so that the payment is received before the due date of maturity claim.

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