Form HCD OL ED123 Part B "Application for Course Provider Approval" - California

What Is Form HCD OL ED123 Part B?

This is a legal form that was released by the California Department of Housing & Community Development - a government authority operating within California.The document is a supplement to Form HCD OL ED123, Application for Course Provider Approval (Part B). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form HCD OL ED123 Part B 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 OL ED123 Part B "Application for Course Provider Approval" - California

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STATE OF CALIFORNIA
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
OCCUPATIONAL LICENSING PROGRAM
APPLICATION FOR COURSE PROVIDER APPROVAL
(PART B)
SECTION 1 – PERSONAL INFORMATION
(Type or Print)
NAME:
______________________________________________________________ TELEPHONE NUMBER: (____) ___________________
Last
First
Middle
RESIDENCE ADDRESS: ____________________________________________________________________________________________
Number and Street
City
State
ZIP Code
MAILING ADDRESS:
_______________________________________________________________________________________________
(If different)
Number and Street or P. O. Box
City
State
ZIP Code
PHYSICAL DESCRIPTION: __________/____________/_____________/_____________/_____________/ ___________________________
Sex
Hair Color
Eye Color
Height
Weight
Birth Date
E-MAIL ADDRESS
: ________________________________________________________________________________________
(If applicable)
SECTION 2 – PERSONAL HISTORY
(Type or Print)
1.
Have you previously been or are you now licensed as a MH-Unit or commercial modular salesperson, distributor, dealer or
manufacturer?
YES______ NO______
If yes, License Number ___________________________ Expiration Date _________________
State __________________
License Number ___________________________ Expiration Date _________________
State __________________
License Number ___________________________ Expiration Date _________________
State __________________
2.
Do you now hold a valid California Driver's License?
YES______ NO______
If yes, provide license number. ____________________________________
3.
Have you ever been known by or used any name other than the name appearing on this application?
YES______ NO______
If yes, provide all names. _________________________________________________________________________________________
4.
Have you had an occupational license refused, revoked, suspended or subject to other disciplinary action?
YES______ NO______
If yes, disclose your name used (if different than shown in Section 1), the business name, the name of the issuing department, type of license
and license number. _____________________________________________________________________________________________
5.
Have you ever been an Owner, a Partner, a Member of an LLC, Officer, Director or Controlling Stockholder in a corporation that had a criminal
judgment rendered against it?
YES______ NO______
If yes, on a separate sheet, disclose for each case your name used (if different than shown in Section 1), the business name, the name of
the court, the amount and date of any criminal penalty and whether the judgment or penalty has been paid.
6.
Excluding traffic offenses, have you ever been convicted, fined or placed on probation or parole for any crime or offense, either felony or
misdemeanor?
YES______ NO______
If yes, list each separate offense below. State if you were pardoned or if the offense was expunged from the record of the court. If you are
currently on probation or parole, show the name and address of your probation or parole officer.
NOTE: A background investigation will be made, and failure to disclose ALL convictions, fines, probations or paroles including those out-of-state or
expunged, may result in a refusal to approve your application.
DISPOSITION OF OFFENSE
(DESCRIBE SENTENCE)
DATE OF
COURT OF JURISDICTION
NATURE OF OFFENSE
CONVICTION
(FULL NAME AND ADDRESS)
Amount
Term of
Jail or
Date
Fined
Probation/Parole
Prison Term
Released
CHECK IF ADDITIONAL PAGE(S) IS/ARE ATTACHED TO PROVIDE THE REQUESTED INFORMATION
SECTION 3 – CERTIFICATION BY APPLICANT
I,
_______________________________________________,
certify under penalty of perjury under the laws of the State of California
Type or Print First and Last Name
that the answers and information contained herein are true and correct to the best of my knowledge and belief. I certify and
acknowledge that I am not authorized to act in the capacity of a course provider until I receive written approval from the California
Department of Housing and Community Development.
SIGNATURE
__________________________________________________________________
DATE
_________________
EXECUTED IN THE COUNTY OF
_____________________________________
STATE OF
___________________________
Page 1 of 1
HCD OL ED 123 (Rev. 08/20)
STATE OF CALIFORNIA
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
OCCUPATIONAL LICENSING PROGRAM
APPLICATION FOR COURSE PROVIDER APPROVAL
(PART B)
SECTION 1 – PERSONAL INFORMATION
(Type or Print)
NAME:
______________________________________________________________ TELEPHONE NUMBER: (____) ___________________
Last
First
Middle
RESIDENCE ADDRESS: ____________________________________________________________________________________________
Number and Street
City
State
ZIP Code
MAILING ADDRESS:
_______________________________________________________________________________________________
(If different)
Number and Street or P. O. Box
City
State
ZIP Code
PHYSICAL DESCRIPTION: __________/____________/_____________/_____________/_____________/ ___________________________
Sex
Hair Color
Eye Color
Height
Weight
Birth Date
E-MAIL ADDRESS
: ________________________________________________________________________________________
(If applicable)
SECTION 2 – PERSONAL HISTORY
(Type or Print)
1.
Have you previously been or are you now licensed as a MH-Unit or commercial modular salesperson, distributor, dealer or
manufacturer?
YES______ NO______
If yes, License Number ___________________________ Expiration Date _________________
State __________________
License Number ___________________________ Expiration Date _________________
State __________________
License Number ___________________________ Expiration Date _________________
State __________________
2.
Do you now hold a valid California Driver's License?
YES______ NO______
If yes, provide license number. ____________________________________
3.
Have you ever been known by or used any name other than the name appearing on this application?
YES______ NO______
If yes, provide all names. _________________________________________________________________________________________
4.
Have you had an occupational license refused, revoked, suspended or subject to other disciplinary action?
YES______ NO______
If yes, disclose your name used (if different than shown in Section 1), the business name, the name of the issuing department, type of license
and license number. _____________________________________________________________________________________________
5.
Have you ever been an Owner, a Partner, a Member of an LLC, Officer, Director or Controlling Stockholder in a corporation that had a criminal
judgment rendered against it?
YES______ NO______
If yes, on a separate sheet, disclose for each case your name used (if different than shown in Section 1), the business name, the name of
the court, the amount and date of any criminal penalty and whether the judgment or penalty has been paid.
6.
Excluding traffic offenses, have you ever been convicted, fined or placed on probation or parole for any crime or offense, either felony or
misdemeanor?
YES______ NO______
If yes, list each separate offense below. State if you were pardoned or if the offense was expunged from the record of the court. If you are
currently on probation or parole, show the name and address of your probation or parole officer.
NOTE: A background investigation will be made, and failure to disclose ALL convictions, fines, probations or paroles including those out-of-state or
expunged, may result in a refusal to approve your application.
DISPOSITION OF OFFENSE
(DESCRIBE SENTENCE)
DATE OF
COURT OF JURISDICTION
NATURE OF OFFENSE
CONVICTION
(FULL NAME AND ADDRESS)
Amount
Term of
Jail or
Date
Fined
Probation/Parole
Prison Term
Released
CHECK IF ADDITIONAL PAGE(S) IS/ARE ATTACHED TO PROVIDE THE REQUESTED INFORMATION
SECTION 3 – CERTIFICATION BY APPLICANT
I,
_______________________________________________,
certify under penalty of perjury under the laws of the State of California
Type or Print First and Last Name
that the answers and information contained herein are true and correct to the best of my knowledge and belief. I certify and
acknowledge that I am not authorized to act in the capacity of a course provider until I receive written approval from the California
Department of Housing and Community Development.
SIGNATURE
__________________________________________________________________
DATE
_________________
EXECUTED IN THE COUNTY OF
_____________________________________
STATE OF
___________________________
Page 1 of 1
HCD OL ED 123 (Rev. 08/20)