STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ADMINISTRATIVE ORGANIZATION (This side is for corporations and limited liability companies only. See reverse for public agencies, partnerships, and other associations.) INSTRUCTIONS: This form must be updated and submitted to the Licensing Agency each time there is a change in partners, officers or changes in the corporation or limited liability company as provided in the Callifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2). DATE FACILITY NAME FACILITY ADDRESS FACILITY NUMBER I. CORPORATION/LIMITED LIABILITY COMPANY (LLC) 1. Name (as filed with Secretary of State) 3. Incorporation/Registration Date 5. 2. 4. Chief Executive Officer Place of Incorporation/Registration Corporation/Limited Liability Company Number Please attach (1) A copy of Articles of Incorporation or organization and any amendments (2) A copy of By-Laws or Operating Agreement and any amendments (3) A copy of Resolution authorizing the filing of this application (for Corporations only). 6. Principal office of business: Address City Zip Code Contact Person: Title: 7. Out of state or foreign applicants complete the following: a. Name of California Representative County Telephone No. Telephone No.: Address Zip Code Telephone No. b. Please attach a copy of a foreign corporation’s or foreign LLC’s registration to do business in California. 8. Names and addresses of all persons who own ten percent (10%) or more interest in corporation or LLC. Attach sheet for additional space. 9. Directors (Corporation)/Managers and Managing Members (LLC) a. Number of Directors/Managers & Managing Members b. Term of Office (if applicable) c. Frequency of Meetings (if applicable) d. Method of Selection (corporations only) 10. Officers: (For LLCs without officers, skip this section and go to Section II) Office Name Principal Business Address & City & Zip Code (other than facility address) Telephone No. Term Expires President Vice-President Secretary Treasurer LIC 309 (6/01) (PUBLIC) American LegalNet, Inc. www.FormsWorkFlow.com 11. List all Directors (Corporations)/Managers and Managing Members (LLC) Name Mailing Address & City & Zip Code Telephone No. Term Expires (Attach Sheet for additional space) II. PUBLIC AGENCY 1. Check type of public agency: 2. Agency providing services: ■ Federal ■ State Name: _______________________________________________ ■ County ■ City ■ Other, specify below Address: ___________________________________________________________ CITY/STATE Mailing Address: _____________________________________________________________________________________________________________ CITY/STATE/ZIP CODE Contact Person: __________________________________ 3. District or Area to be served: Title: ___________________________________ Phone No.:_______________________ (attach map if necessary) Specify geographic area: 4. Attach copy of Resolution or legal document authorizing this application. III. PARTNERSHIPS Attach a copy of partnership agreement (attach additional sheet if necessary) 1st Partner ■ General Name TELEPHONE NUMBER ■ Limited Principal Business Address CITY/STATE 2nd Partner ■ General Name TELEPHONE NUMBER ■ Limited Principal Business Address CITY/STATE 3rd Partner ■ General Name TELEPHONE NUMBER ■ Limited Principal Business Address CITY/STATE 4th Partner ■ General Name TELEPHONE NUMBER ■ Limited Principal Business Address CITY/STATE Contact Person: _______________________________ IV. Title: __________________________________ Telephone No.: ___________________ OTHER ASSOCIATIONS Other associations must also provide a similar list of persons legally responsible for the organization, contact person, appropriate legal documents which set forth legal responsibility of the organization and accountability for operating the facility. American LegalNet, Inc. www.FormsWorkFlow.com