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Lic9141 2004 form

Lic9141 2004 form-2026

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69 votes

The document is an application form for becoming or renewing a course vendor in the Administrator Certification Program by the California Department of Social Services. It outlines the necessary steps, including submitting a completed application and processing fee, specifying the type of program and vendor, and providing applicant information. The form also requires certification of the provided information and includes sections for legal and professional background related to care facility licensing.

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Click ‘Get Form’ to open the lic9141 2004 form in the editor.
Begin by selecting the type of application: either 'New' or 'Renewal'. If renewing, ensure to provide your vendor number and expiration date.
Next, indicate the type of program you are applying for by checking one box: ARF, GH, RCFE, or STRTP. Remember to submit separate applications for multiple programs.
Select the type of vendor you wish to apply as: ICTP or CEU. Note the associated fees for each option.
Fill in your organization’s information including name, address, and contact details. Ensure accuracy as this information is crucial for processing.
List all authorized representatives and their titles. Each must complete and sign Sections 6-10 on page 2.
Complete the applicant certification section by signing and dating it to confirm that all provided information is accurate.

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Versions	Form popularity	Fillable & printable
2016	4.9 Satisfied (452 Votes)
2004	4.1 Satisfied (69 Votes)

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