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LIC 9142A (3/06) - Roster Of Participants - California Department of ... - dss cahwnet

LIC 9142A (3/06) - Roster Of Participants - California Department of ... - dss cahwnet 2025

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The document is a roster template for the California Department of Social Services, intended for vendors to record participants in various Administrator Certification Program courses. It outlines the required information to be submitted within 7 days of course completion, including participant names, course details, and vendor information.

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Click ‘Get Form’ to open it in the editor.
Begin by selecting the Course Program Type. Check the appropriate box for RCFE, ARF, or GH courses.
Enter the Vendor Name and Instructor(s) Name in the designated fields.
Fill in the Course Name, Location of Course, and Course Date accurately.
For each participant, print their Last Name, First Name, Address, City, and Phone Number in the provided fields.
Complete sections for Time In and Time Out for each participant to track attendance.
Finally, have the Authorized Representative sign and date the form at the bottom before submission.

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Versions	Form popularity	Fillable & printable
2016	4.9 Satisfied (323 Votes)
2006	4.3 Satisfied (64 Votes)

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LIC 9142A (3/06) - Roster Of Participants - California Department of ... - dss cahwnet 2025

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