CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA 9821 Business Park Drive, Sacramento, California 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800-321-CSLB (2752)www.cslb.ca.gov CheckTheLicenseFirst.com Disassociation Request Use this form to notify CSLB of the disassociation of a General Partner, Qualifying Partner, Officer, Responsible Managing Officer (RMO), or Responsible Managing Employee (RME). This notice must be received at CSLB Headquarters within 90 days after the effective date of the disassociation. If the notice is received after 90 days, the date CSLB receives it will be used as the disassociation date. This may result in the suspension or cancellation of the license or the removal of a classification from the license, effective that date. (See Business and Professions Code Sections 7076, 7068.2 and 7083.) DISASSOCIATION OF A GENERAL PARTNER OR QUALIFYING PARTNER If a partner disassociates from a license, it results in the cancellation of the partnership license. Pursuant to Business & Professions Code Section 7076, the remaining partner(s) may request a continuance to complete projects in progress. To disassociate a limited partner, use form 13A-62, the Application to Change Limited Partners of a Partnership. DISASSOCIATION OF AN RME OR RMO When an RME or RMO disassociates from a license, the licensee or the RME or RMO must notify the Registrar in writing. The licensee must replace the qualifier within 90 days of the disassociation date. Failure to replace the qualifier within 90 days results in the automatic suspension of the license or removal of the classification. If a licensee is unable to replace the RME or RMO within the 90-day period, a 90-day extension can be requested. An extension request will only be considered if received within 90 days from the date of the Board222s notice that the license will be suspended or the classification removed and if an application has been made to CSLB to replace the qualifying individual. Please type or print neatly and legibly in black or dark blue ink. SECTION 1 Name of Business Disassociating from (as it currently appears on CSLB records) License Number Business Mailing Address (number/street or P.O. box) City State Zip Code Name of Person Disassociating Daytime Phone Number ( )Mailing Address of Person Disassociating (number/street or P. O. box) City State Zip Code Date of Disassociation SECTION 2 On at DATECITY/COUNTY/STATEI certify under penalty of perjury under the laws of the State of California that all statements, answers and representations in this application are true and correct and that I have reviewed the entire contents of this application. FALSIFICATION OF ANY DOCUMENT IS GROUNDS FOR DISCIPLINARY ACTION. Signature of Disassociating Contractor (Owner, General Partner, Qualifying Partner, Officer, Printed Name RME, or RMO) ATTENTION QUALIFIERS: If you were required to inactivate your individual license to Reactivation Application requested for License Number: qualify the above license, and now want to reactivate your individual license, provide your license number and a Reactivation Application will be mailed to you. NOTICE ON COLLECTION OF PERSONAL INFORMATION CSLB collects the personal information requested on this form as authorized by Business and Professions Code Section 30. 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 this Disassociation Request 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. This application contains an applicant authorization for the Franchise Tax Board to disclose to CSLB any outstanding final liabilities for the purpose of administering Business and Professions Code Section 7145.5. For more information on the Information Practices Act, visit the Office of Privacy Protection222s website at www.privacy.ca.gov. *DISASSOC-REQ* 13M-5 (Rev. 5-2011) American LegalNet, Inc. www.FormsWorkFlow.com