Form HCD OL90A "Application for 90-day Certificate Change, Correction or Replacement" - California

What Is Form HCD OL90A?

This is a legal form that was released by the California Department of Housing & Community Development - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2009;
  • The latest edition provided by the California Department of Housing & Community Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form HCD OL90A by clicking the link below or browse more documents and templates provided by the California Department of Housing & Community Development.

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Download Form HCD OL90A "Application for 90-day Certificate Change, Correction or Replacement" - California

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STATE OF CALIFORNIA
BUSINESS, TRANSPORTATION AND HOUSING AGENCY
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
OCCUPATIONAL LICENSING PROGRAM
APPLICATION FOR 90-DAY CERTIFICATE CHANGE, CORRECTION OR REPLACEMENT
SECTION 1 – PURPOSE OF APPLICATION
Check the appropriate box(es) to indicate the purpose of this application submittal and follow the instructions provided.
CHANGE OF RESIDENCE
Certificate Holder: Complete Sections 1, 2 and 7, include the old 90-DAY CERTIFICATE and the fee
of $45 with this application
TERMINATION
Dealer: Complete Sections 1 and 3
PERSONAL NAME CHANGE
Certificate Holder: Complete Sections 1, 4 and 7, include the old 90-DAY CERTIFICATE and the fee
of $45 with this application
EMPLOYMENT LOCATION CHANGE
Dealer: Complete Sections 1 and 5, include the old 90-DAY CERTIFICATE and the fee of $45 with
(Same Employing Dealer)
this application
REPLACEMENT 90-DAY CERTIFICATE
Certificate Holder: Complete Sections 1, 6 and 7, include the 90-DAY CERTIFICATE, if available,
and the fee of $45 with this application
NOTE:
COMPLETE SECTION 8 IF THE OLD 90-DAY CERTIFICATE IS NOT RETURNED WHEN REQUIRED.
This application shall be accompanied by the appropriate fees in accordance with the California Code of Regulations, Title 25, Chapter 4,
Section 5040.
CERTIFICATE HOLDER’S NAME: ___________________________________________________________________________________________
Type or Print First, Middle and Last Name
90-DAY CERTIFICATE NUMBER: _____________________________ E-MAIL ADDRESS (If applicable): __________________________________
SECTION 2 – CHANGE OF RESIDENCE
(Type or Print)
NEW RESIDENCE ADDRESS: _____________________________________________________________________________________________
Number and Street
City
State
ZIP Code
MAILING ADDRESS (If different): ___________________________________________________________________________________________
Number and Street or P.O. Box
City
State
ZIP Code
TELEPHONE NUMBER: (____) __________________________
EFFECTIVE DATE: _____________________________
SECTION 3 – TERMINATION
(Type or Print)
DEALER LICENSE NUMBER: _______________________________________________
DEALERSHIP NAME: _____________________________________________________________________________________________________
DEALER’S REPRESENTATIVE: _________________________________________________ TITLE: ____________________________________
Last
First
SIGNATURE: _______________________________________________________
EFFECTIVE DATE: ______________________________
SECTION 4 – PERSONAL NAME CHANGE
(Type or Print)
NEW NAME: _____________________________________________________________ EFFECTIVE DATE: ______________________________
Last
First
Middle
FORMER NAME: _____________________________________________________________
Last
First
Middle
SECTION 5 – EMPLOYMENT LOCATION CHANGE -
Same employing dealer
(Type or Print)
DEALER LICENSE NUMBER: _______________________________________________
DEALERSHIP NAME: ______________________________________________________________________________________________________
NEW EMPLOYMENT LOCATION: ____________________________________________________________________________________________
Number and Street
City
State
ZIP Code
FORMER EMPLOYMENT LOCATION: ________________________________________________________________________________________
Number and Street
City
State
ZIP Code
EFFECTIVE DATE: ______________________________
Page 1 of 2
HCD OL 90A (Rev. 06/09)
STATE OF CALIFORNIA
BUSINESS, TRANSPORTATION AND HOUSING AGENCY
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
OCCUPATIONAL LICENSING PROGRAM
APPLICATION FOR 90-DAY CERTIFICATE CHANGE, CORRECTION OR REPLACEMENT
SECTION 1 – PURPOSE OF APPLICATION
Check the appropriate box(es) to indicate the purpose of this application submittal and follow the instructions provided.
CHANGE OF RESIDENCE
Certificate Holder: Complete Sections 1, 2 and 7, include the old 90-DAY CERTIFICATE and the fee
of $45 with this application
TERMINATION
Dealer: Complete Sections 1 and 3
PERSONAL NAME CHANGE
Certificate Holder: Complete Sections 1, 4 and 7, include the old 90-DAY CERTIFICATE and the fee
of $45 with this application
EMPLOYMENT LOCATION CHANGE
Dealer: Complete Sections 1 and 5, include the old 90-DAY CERTIFICATE and the fee of $45 with
(Same Employing Dealer)
this application
REPLACEMENT 90-DAY CERTIFICATE
Certificate Holder: Complete Sections 1, 6 and 7, include the 90-DAY CERTIFICATE, if available,
and the fee of $45 with this application
NOTE:
COMPLETE SECTION 8 IF THE OLD 90-DAY CERTIFICATE IS NOT RETURNED WHEN REQUIRED.
This application shall be accompanied by the appropriate fees in accordance with the California Code of Regulations, Title 25, Chapter 4,
Section 5040.
CERTIFICATE HOLDER’S NAME: ___________________________________________________________________________________________
Type or Print First, Middle and Last Name
90-DAY CERTIFICATE NUMBER: _____________________________ E-MAIL ADDRESS (If applicable): __________________________________
SECTION 2 – CHANGE OF RESIDENCE
(Type or Print)
NEW RESIDENCE ADDRESS: _____________________________________________________________________________________________
Number and Street
City
State
ZIP Code
MAILING ADDRESS (If different): ___________________________________________________________________________________________
Number and Street or P.O. Box
City
State
ZIP Code
TELEPHONE NUMBER: (____) __________________________
EFFECTIVE DATE: _____________________________
SECTION 3 – TERMINATION
(Type or Print)
DEALER LICENSE NUMBER: _______________________________________________
DEALERSHIP NAME: _____________________________________________________________________________________________________
DEALER’S REPRESENTATIVE: _________________________________________________ TITLE: ____________________________________
Last
First
SIGNATURE: _______________________________________________________
EFFECTIVE DATE: ______________________________
SECTION 4 – PERSONAL NAME CHANGE
(Type or Print)
NEW NAME: _____________________________________________________________ EFFECTIVE DATE: ______________________________
Last
First
Middle
FORMER NAME: _____________________________________________________________
Last
First
Middle
SECTION 5 – EMPLOYMENT LOCATION CHANGE -
Same employing dealer
(Type or Print)
DEALER LICENSE NUMBER: _______________________________________________
DEALERSHIP NAME: ______________________________________________________________________________________________________
NEW EMPLOYMENT LOCATION: ____________________________________________________________________________________________
Number and Street
City
State
ZIP Code
FORMER EMPLOYMENT LOCATION: ________________________________________________________________________________________
Number and Street
City
State
ZIP Code
EFFECTIVE DATE: ______________________________
Page 1 of 2
HCD OL 90A (Rev. 06/09)
SECTION 6 – REPLACEMENT 90-DAY CERTIFICATE
(Type or Print)
90-DAY CERTIFICATE NUMBER: _____________________________________________
CERTIFICATE HOLDER’S NAME: __________________________________________________________________________________________
Last
First
Middle
ADDRESS: _____________________________________________________________________________________________________________
Number and Street
City
State
ZIP Code
MAILING ADDRESS
: ____________________________________________________________________________________________
(If different)
Number and Street or P.O. Box
City
State
ZIP Code
REPLACEMENT IS DUE TO:
LOSS
MUTILATION
ERROR
OTHER ___________________________________
Briefly explain circumstances: ______________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
SECTION 7 – CERTIFICATE HOLDER CERTIFICATION
I, ______________________________________________________________________________________________________, certify under penalty
Type or Print First, Middle and Last Name
of perjury under the laws of the State of California that the information contained herein is true and correct to the best of my belief.
SIGNATURE ____________________________________________________________ DATE ___________________________________________
SECTION 8 – STATEMENT OF FACTS
(Type or Print)
I, ______________________________________________________________________________________________________, the under signed,
Type or Print First, Middle and Last Name
hereby declare that I am unable to surrender the 90-DAY CERTIFICATE required to be returned with the Application for a 90-Day Certificate Change,
Correction, or Replacement because:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
I further acknowledge that said 90-Day Certificate remains the property of the California Department of Housing and Community Development.
Should the 90-Day Certificate be located or come into my possession at a later date, I will surrender it to the California Department of Housing and
Community Development Office.
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION GIVEN ON THIS
APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SIGNATURE ______________________________________________________________ DATE _________________________________________
EXECUTED IN THE COUNTY OF _____________________________________________ STATE OF______________________________________
Department of Housing and Community Development
SUBMIT APPLICATION, ATTACHMENTS AND FEES TO:
Division of Codes and Standards
Occupational Licensing Program
P.O. Box 31
Sacramento, CA 95812-0031
Page 2 of 2
HCD OL 90A (Rev. 06/09)
Page of 2