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) 2. Chief Executive Officer 3. Incorporation/Registration Date 4. Place of Incorporation/Registration Corporation/Limited Liability Company Number 5. 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). City Zip Code County Telephone No.: Address Zip Code Telephone No. Telephone No. 6. Principal office of business: Address Contact Person: Title: 7. Out of state or foreign applicants complete the following: a. Name of California Representative 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. b. c. Number of Directors/Managers & Managing Members Term of Office (if applicable) 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 President Name Principal Business Address & City & Zip Code (other than facility address) Telephone No. Term Expires 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. 1. 2. PUBLIC AGENCY Check type of public agency: Agency providing services: Name: _______________________________________________ Address: ___________________________________________________________ CITY/STATE Federal State County City Other, specify below Mailing Address: _____________________________________________________________________________________________________________ CITY/STATE/ZIP CODE Contact Person: __________________________________ 3. District or Area to be served: Specify geographic area: (attach map if necessary) Title: ___________________________________ Phone No.:_______________________ 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 Limited General Limited General Limited General Limited Name TELEPHONE NUMBER Principal Business Address CITY/STATE 2nd Partner Name TELEPHONE NUMBER Principal Business Address CITY/STATE 3rd Partner Name TELEPHONE NUMBER Principal Business Address CITY/STATE 4th Partner Name TELEPHONE NUMBER Principal Business Address CITY/STATE Contact Person: _______________________________ Title: __________________________________ Telephone No.: ___________________ IV. 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