Form LIC-309 "Administrative Organization" - California

What Is Form LIC-309?

This is a legal form that was released by the California Department of Social Services - 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, 2001;
  • The latest edition provided by the California Department of Social Services;
  • 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 LIC-309 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC-309 "Administrative Organization" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ADMINISTRATIVE ORGANIZATION
DATE
(This side is for corporations and limited liability companies only. See reverse for public agencies,
partnerships, and other associations.)
FACILITY NAME
INSTRUCTIONS:
This form must be updated and submitted to the Licensing Agency each time there is a change
FACILITY ADDRESS
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).
FACILITY NUMBER
I. CORPORATION/LIMITED LIABILITY COMPANY (LLC)
1.
Name (as filed with Secretary of State)
2.
Chief Executive Officer
4.
Place of Incorporation/Registration
Corporation/Limited Liability Company Number
3.
Incorporation/Registration Date
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).
6. Principal office of business:
Address
City
Zip Code
County
Telephone No.
Contact Person:
Title:
Telephone No.:
7. Out of state or foreign applicants complete the following:
a. Name of California Representative
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)
Principal Business Address & City & Zip Code
Office
Name
Telephone No.
Term Expires
(other than facility address)
President
Vice-President
Secretary
Treasurer
LIC 309 (6/01) (PUBLIC)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ADMINISTRATIVE ORGANIZATION
DATE
(This side is for corporations and limited liability companies only. See reverse for public agencies,
partnerships, and other associations.)
FACILITY NAME
INSTRUCTIONS:
This form must be updated and submitted to the Licensing Agency each time there is a change
FACILITY ADDRESS
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).
FACILITY NUMBER
I. CORPORATION/LIMITED LIABILITY COMPANY (LLC)
1.
Name (as filed with Secretary of State)
2.
Chief Executive Officer
4.
Place of Incorporation/Registration
Corporation/Limited Liability Company Number
3.
Incorporation/Registration Date
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).
6. Principal office of business:
Address
City
Zip Code
County
Telephone No.
Contact Person:
Title:
Telephone No.:
7. Out of state or foreign applicants complete the following:
a. Name of California Representative
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)
Principal Business Address & City & Zip Code
Office
Name
Telephone No.
Term Expires
(other than facility address)
President
Vice-President
Secretary
Treasurer
LIC 309 (6/01) (PUBLIC)
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
I I
I I
I I
I I
I I
Federal
State
County
City
Other, specify below
1.
Check type of public agency:
2.
Agency providing services:
Name: _______________________________________________
Address: ___________________________________________________________
CITY/STATE
Mailing Address: _____________________________________________________________________________________________________________
CITY/STATE/ZIP CODE
Contact Person: __________________________________
Title: ___________________________________ Phone No.:_______________________
3.
District or Area to be served:
(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)
I I
1st Partner
General
Name
TELEPHONE NUMBER
I I
Limited
Principal Business Address
CITY/STATE
I I
2nd Partner
General
Name
TELEPHONE NUMBER
I I
Limited
Principal Business Address
CITY/STATE
I I
3rd Partner
General
Name
TELEPHONE NUMBER
I I
Limited
Principal Business Address
CITY/STATE
I I
4th Partner
General
Name
TELEPHONE NUMBER
I I
Limited
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.
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