CONTRACTORS STATE LICENSE BOARD 9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com STATE OF CALIFORNIA Governor Edmund G. Brown Jr. IMPORTANT NOTICE REGARDING CONVICTIONS PLEASE READ CAREFULLY Failure to accurately report a conviction can result in an application being denied. In this notice and on the application, the term “conviction” includes pleading guilty or no contest to (nolo contendere) or being convicted by a court of any misdemeanor or felony in this state or elsewhere. As part of the Contractors State License Board (CSLB) application process, you must be fingerprinted if you have not been fingerprinted by CSLB before or if your previous fingerprint record was purged by CSLB due to a voided application or some other reason. After an application is accepted by CSLB as complete (also known as “posted”), each individual listed on the application will be sent instructions on the process for obtaining and submitting fingerprints, as required by law. Your fingerprints will be compared to the records of the California Department of Justice and the Federal Bureau of Investigation. If you have ever been convicted of a crime, your criminal record information will be reported to CSLB. This includes DUIs and other Vehicle Code violations resulting in a misdemeanor or felony conviction. Even if you have had your record expunged (charges reduced or dismissed), the past conviction will still be reported to CSLB and must be disclosed on the application. If you have ever been convicted of a crime (misdemeanor or felony), you MUST answer “Yes” to the criminal conviction question on the application and provide a detailed explanation of the circumstances resulting in your conviction. To help ensure that you provide the required information, you should complete and submit the Disclosure Statement Regarding Criminal Plea/Conviction form that is available on CSLB’s website. Applicants with criminal convictions are not automatically denied licensure – each application is reviewed individually based on applicable sections of law. When reviewing criminal convictions, CSLB considers factors such as the nature and severity of the crimes, the amount of time that has passed since the convictions, and any evidence of rehabilitation submitted by the applicant. For rehabilitation evaluation, pursuant to the California Code of Regulations Section 869, CSLB is generally looking for three (3) years to have passed after a misdemeanor conviction and seven (7) years to have passed after a felony conviction, without further violation of law. These timeframes are calculated from the applicant’s date of release from incarceration or from the end of probation if no time was served, and are subject to reduction or extension based on several factors, including the nature of the applicant’s conviction history as a whole. In addition, any type of conviction could be considered substantially related to the qualifications or duties of a contractor license when evaluated in the context of the applicant’s entire conviction record. Failure to accurately report any and all convictions is falsification of your application and is grounds for denial. If your application is denied, you will be prevented from filing another application for a minimum of one (1) year, up to a maximum of five (5) years. 13A-7b (05/2012) American LegalNet, Inc. www.FormsWorkFlow.com FOR CSLB USE ONLY STATE OF CALIFORNIA 9821 Business Park Drive, Sacramento, CA 95827 Governor Edmund G. Brown Jr. Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800-321-CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com CONTRACTORS STATE LICENSE BOARD Application to Add New Personnel to a Limited Liability Company (LLC) – No Fee Use this application only to add NEW personnel to an existing LLC license.  Use one form for each new member, manager, or officer. Each additional member, manager, or officer must use a separate form.  If you have additional licenses with the same LLC registration number, you must submit a copy of this form for each license. All licenses using the same LLC registration number must show the same members, managers, and officers.  To report a change of title for current personnel on this license, use form 13A-7c – Application to Report Change of Title for Current Personnel of a Limited Liability Company (LLC).  To disassociate a member, manager, or officer, including a responsible managing member, responsible managing manager, responsible managing officer (RMO), or responsible managing employee (RME), use form 13M-5 – Disassociation Request.  To replace a current responsible managing member, responsible managing manager, RMO, or RME, use form 13A-20a – Application for Limited Liability Company (LLC) Replacing the Qualifying Individual. Please type or print neatly and legibly in black or dark blue ink. SECTION 1 – BUSINESS NAME AND ADDRESS Please provide the full legal business name as it appears on the license. P.O. Boxes and private mail boxes (PMB) are not acceptable for the street address. 1. FULL BUSINESS NAME 2. CSLB LICENSE NUMBER 3. LLC REGISTRATION NUMBER 4. BUSINESS MAILING ADDRESS – Number/Street or P.O. Box City State ZIP Code 5. BUSINESS STREET ADDRESS – Number/Street Only – NO P.O. Boxes or PMBs City State ZIP Code 6. BUSINESS PHONE NUMBER ( ) BUSINESS FAX NUMBER ( BUSINESS EMAIL ADDRESS ) SECTION 2 – NEW LLC PERSONNEL’S FULL LEGAL NAME AND ADDRESS Please provide the full legal name of the member of the personnel. If the individual does not have a middle name, write “None” or “No Middle Name” in the space provided. If the individual has only an initial for his or her first or middle name, write “(Initial Only)” after the initial. 7. NEW PERSONNEL’S FULL LEGAL NAME – Last First Middle DATE OF BIRTH RESIDENCE ADDRESS – Number/Street Only – NO P.O. Boxes or PMBs LLC TITLE(S) – May NOT be an RMO or RME (see above) City HOME PHONE NUMBER ( SOCIAL SECURITY NUMBER State ZIP Code DRIVER LICENSE NUMBER ) I/we certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and accurate, and that I/we have reviewed the entire contents of this application. (The definition of “perjury” is telling a lie while under oath.) I/we authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5. Date Signature of NEW LLC Personnel Printed Name of New LLC Personnel Date Signature of Personnel Currently Listed on LLC License Printed Name of Current LLC Personnel *chng-Pers-llc* 13A-7b (05/2012) Application – Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 – REQUIRED APPLICATION QUESTIONS All questions in this section must be answered. Questions 8 through 10 pertain to new personnel listed on this application. If you check “Yes” in response to any question, you must attach a separate sheet with a detailed explanation for each situation. 8. To the best of your knowledge, is anyone listed on this application (or any company the person is or was a part of, or any immediate family member of the applicant) named in or responsible for any entered and unsatisfied judgments, liens, and/or claims against any bond or cash deposit pertaining to a construction project? (Immediate family member is defined by B&P Code Section 7075.1 as a spouse, father, mother, brother, sister, son, daughter, stepson, stepdaughter, grandson, granddaughter, son-in-law, or daughter-in-law.) □ Yes If you check “Yes” for this question, you are required to attach a statement identifying all judgments (pending or on record), liens, past due unpaid bills, claims, or suits and a detailed explanation of the situation. Include the names and addresses of the parties involved. If the obligation was or is being discharged in bankruptcy, attach a copy of the bankruptcy filing and a copy of the creditors list. □ No □ Yes □ No □ Yes □ No 9. Has anyone listed on this application ever pleaded guilty or no contest to or been convicted by a court of any misdemeanor or felony in this state or elsewhere? You are required to check “Yes” and provide all of the requested information even if the conviction was sealed or expunged under Penal Code Section 1203.4 or an applicable code of another state. If you check “Yes” for this question, you are required to attach a statement disclosing all pleas/convictions, including violated law sections, and thoroughly explain the acts or circumstances which resulted in the plea/conviction. In addition, the following information must be included for each plea/conviction: date of the plea/conviction, county and state where the violation took place, name of the court, court case number, sentence imposed, jail/prison term served, terms and conditions of parole or probation, parole or probation completion dates, and parole agent/probation officer names and phone numbers. You may submit the required information using the Disclosure Statement Regarding Criminal Plea/Conviction form that is available on the Forms and Applications page on CSLB’s website. The information provided will be verified through CSLB’s fingerprinting requirement. Failure to report a plea/conviction is considered falsification of your application and is grounds for denial of your application. 10. To the best of your knowledge, has anyone on this application (or any company the person was a part of, or any immediate family member of the applicant) ever received a citation from the Contractors State License Board or had a contractor license or other professional or vocational license or registration denied, suspended, or revoked by this state or elsewhere? (Check “No” if the license was suspended due to lack of a bond, workers’ compensation, a qualifier, or family support.) If you check “Yes” for this question, you are required to attach a statement detailing the events leading to this action. FINGERPRINT REQUIREMENT All applicants for licensure are required to submit a full set of fingerprints for the purpose of conducting a criminal background check. Fingerprints will be compared to the records of the California Department of Justice and the Federal Bureau of Investigation to determine whether a criminal history exists. After an application has been accepted by CSLB as complete (also known as “posted”), the individual listed on the application will be sent instructions on the process for obtaining and submitting fingerprints as required by law. For more information, please visit CSLB’s website and view information under the Applicants tab. COLLECTION OF SOCIAL SECURITY NUMBERS With the exception of the driver license numbers, all information requested on the application is mandatory, including disclosure of U.S. Social Security numbers (SSN). Collection of the SSN is authorized by B&P Code Section 30 and Public Law 94-455 (42 U.S.C.A. 405(c)(2)(C)). SSNs are used exclusively for the purpose of tax enforcement and/or compliance with any judgment or order for family support in accordance with Family Code Section 17520. If you fail to disclose your SSN, you will be reported to the Franchise Tax Board, and they may assess a $100 penalty against you. The official responsible for the maintenance of this information is the Registrar of Contractors, Contractors State License Board. The information may be transferred to other state or government agencies. Individuals have the right to review files or records about them maintained by the agency, unless the records are identified as confidential information and exempted from the Information Practices Act, Civil Code Section 1798.3. COLLECTION OF PERSONAL INFORMATION CSLB collects the personal information requested on this form as authorized by B&P Code Section 30 and California Code of Regulations (CCR) Section 816. CSLB uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Submission of the requested information is mandatory. CSLB cannot consider your application for licensure or renewal unless you provide all of the requested information. You may review the records maintained by CSLB that contain your personal information, as permitted by the Information Practices Act. CSLB makes every effort to protect the personal information you provide us; however, it may be disclosed in response to a Public Records Act request as allowed by the Information Practices Act; to another government agency as required by state or federal law; or in response to a court or administrative order, a subpoena, or a search warrant. The application contains an applicant authorization for the Franchise Tax Board to disclose to CSLB any outstanding final liabilities for the purpose of administering B&P Code Section 7145.5. For more information on the Information Practices Act, visit the Office of Privacy Protection’s website at www.privacy.ca.gov, or call (866) 785-9663. 13A-7b (05/2012) Application – Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com