FOR CSLB USE ONLY CONTRACTORS STATE LICENSE BOARD 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 Application to Report Change of Title for Current Personnel of a Limited Liability Company (LLC) – No Fee Use this application only to change the title of a current member of the personnel already on record.  Use one form for each personnel title change. Each additional member of the personnel of record 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 add a new member of the personnel to an LLC, use form 13A-7b Application to Add New Personnel to a Limited Liability Company (LLC).  To disassociate a member of the personnel, including a responsible managing officer (RMO) or responsible managing employee (RME), use form 13M-5, Disassociation Request.  To replace a current RMO or RME, use form 13A-20a, Application for Limited Liability Company (LLC) Replacing the Qualifying Individual. Please type or print legibly in black or 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 5. BUSINESS STREET ADDRESS – Number/Street Only – No P.O. Boxes or PMBs City ( ) ZIP Code State BUSINESS FAX NUMBER 6. BUSINESS PHONE NUMBER ( State ZIP Code BUSINESS E-MAIL ADDRESS ) SECTION 2 – LLC PERSONNEL’S FULL LEGAL NAME, ADDRESS, AND NEW TITLE 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. DATE OF BIRTH SOCIAL SECURITY NUMBER HOME PHONE NUMBER 7. PERSONNEL’S FULL LEGAL NAME – Last First Middle ( ) NEW PERSONNEL TITLE – May not be an RMO or RME (see above) 8. CURRENT PERSONNEL TITLE I 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 have reviewed the entire contents of this application. (The definition of “perjury” is telling a lie while under oath.) I authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to Business and Professions (B&P) Code Section 7145.5. Date Signature of LLC Personnel Printed Name of LLC Personnel 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. *chng-LLC-title* 13A-7c (05/2012) FOR CSLB USE ONLY Application – Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com