State of California--Health and Human Services Agency California Department of Public Health ADMINISTRATIVE ORGANIZATION This side is for corporations only. See reverse for other organizations. CORPORATION 1. Name (as filed with Secretary of State) 3. Incorporation date 4. Place of incorporation 2. Administrator 5. Please attach (1) a copy of Articles of Incorporation and any amendments, (2) a copy of by-laws and any amendments, (3) a copy of resolution authorizing the filing of this application. 6. Principal Office of Business Address City ZIP code County Phone number 7. Foreign (out-of-state) applicants complete the following: a. Name of California Representative Address City ZIP code Phone number b. Please attach a copy of authorization of a foreign corporation to do business in California. 8. If applicant has ever owned or operated a facility, please list the name of each facility, address, size, type of care provided, and the dates and duration of ownership or operation. (if more space is needed, please attach a separate list.) 9. Governing Board of Directors Size of Board Term of office Frequency of meetings Method of selection 10. Board Officers Office Name Term Expires RELEASE OF INFORMATION STATEMENT The information provided on this form is mandatory and is necessary for licensure approval. It will be used to determine individual applicants or applicant facility's ability to provide health services. The information is requested by the Department of Public Health, Licensing and Certification, in accordance with Health and Safety Code, Sections 1212, 1253, 1265, 1267.5, and 1728, and California Code of Regulations (CCR), Title 22, Sections 70107, 71107, 73205, 74105, 76205, and 78205. Failure to provide the information as requested may result in nonissuance of a license or license revocation. The information is considered public information and will be made available to the public upon request. The information shall be included and maintained in the individual facility's public files located in Licensing and Certification district offices. HS 309 (10/11) American LegalNet, Inc. www.FormsWorkFlow.com State of California--Health and Human Services Agency California Department of Public Health ORGANIZATIONAL STRUCTURE See other side for corporations. PUBLIC AGENCY 1. Check type of public agency: 2. Agency providing services: Name Address Federal Mailing Address (if different from above) Contact person Title Phone number 3. District or area to be served: (attach map if necessary) Specify geographic area 4. Required supplemental materials: Attach a copy of Resolution or legal document authorizing this application. 5. (1267.5 Health and Safety Code) For profit corporations and partnerships, list the name(s) and business address of each person having a beneficial ownership interest of 10 percent or more in the applicant corporation or partnership. If person is a minor, identify and indicate by name and address who exercises rights during minor's minority. PARTNERSHIPS Attach a copy of partnership agreement. First partner Limited General Name Business address Second partner Limited General Name Business address For additional partners, use space above or attach a separate sheet. OTHER ASSOCIATIONS/BUSINESS ENTITIES Other associations/business entities, i.e., limited liability companies, etc., must also provide a similar list of persons legally responsible for the organization, appropriate legal documents which set forth legal responsibility of the organization, and accountability for operating the facility. RELEASE OF INFORMATION STATEMENT The information provided on this form is mandatory and is necessary for licensure approval. It will be used to determine individual applicant's or applicant facility's ability to provide health services. The information is requested by the Department of Public Health, Licensing and Certification, in accordance with Health and Safety Code, Sections 1212, 1253, 1265, 1267.5, and 1728, and California Code of Regulations (CCR), Title 22, Sections 70107, 71107, 73205, 74105, 76205, and 78205. Failure to provide the information as requested may result in nonissuance of a license or license revocation. The information is considered public information and will be made available to the public upon request. The information shall be included and maintained in the individual facility's files located in Licensing and Certification district offices. HS 309 (10/11) American LegalNet, Inc. www.FormsWorkFlow.com